MEDICARE: GASCONADE COUNTY COUNSELING SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	004797	MO

General Provider Information

NPI Number	:	1649278326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GASCONADE COUNTY COUNSELING SERVICES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 294
Second Line	:	1202 MARKET STREET
City	:	HERMANN
State	:	MO
Zip	:	65041-0294
Country	:	US
Telephone Number	:	573-486-0136
Fax Number	:	573-486-5042

Provider Business Practice Location Address
First Line	:	1202 MARKET ST
Second Line	:
City	:	HERMANN
State	:	MO
Zip	:	65041-1421
Country	:	US
Telephone Number	:	573-486-0136
Fax Number	:	573-486-5042

Authorized Official
Title or Position	:	SENIOR CLINICIAN
Name	:	MRS. DIANE V. HARTMAN
Credential	:	M.S.W., L.C.S.W.
Telephone Number	:	573-486-0136

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	08/22/2020

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