MEDICARE: MIDWEST COUNSELING AND ASSESSMENT, LLC

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	103TC0700X	Clinical Psychologist	2010030531	MO

General Provider Information

NPI Number	:	1841720547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST COUNSELING AND ASSESSMENT, LLC

Provider Business Mailing Address
First Line	:	408 WASHINGTON AVE STE 107
Second Line	:
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-3404
Country	:	US
Telephone Number	:	417-255-8790
Fax Number	:	417-222-6991

Provider Business Practice Location Address
First Line	:	408 WASHINGTON AVE STE 107
Second Line	:
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-3404
Country	:	US
Telephone Number	:	417-255-8790
Fax Number	:	417-222-6991

Authorized Official
Title or Position	:	OWNER, LICENSED PSYCHOLOGIST
Name	:	DR. JENNIFER LONG
Credential	:	PSYD
Telephone Number	:	417-425-2565

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	07/21/2022

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