Provider Demographics
NPI:1235304098
Name:ESCAPE A&D, LLC
Entity Type:Organization
Organization Name:ESCAPE A&D, LLC
Other - Org Name:ESCAPE OUTPATIENT CHEMICAL DEPENDENCY COUNSELING CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO PRIMARY THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:EAMES
Authorized Official - Suffix:
Authorized Official - Credentials:MS MAC CASAC CCCJS
Authorized Official - Phone:660-263-7552
Mailing Address - Street 1:501 N AULT ST
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-2506
Mailing Address - Country:US
Mailing Address - Phone:660-263-7552
Mailing Address - Fax:660-263-6593
Practice Address - Street 1:501 N AULT ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-2506
Practice Address - Country:US
Practice Address - Phone:660-263-7552
Practice Address - Fax:660-263-6593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1253-10266251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOSATOP 066OtherMO STATE CERTIFIED SUBSTANCE ABUSE TRAFFIC OFFENDER PROGRAMS
MAC 501662OtherNATIONAL ASSOCIATION OF ALCOHOL & DRUG ABUSE COUNSELORS
MOVENDOR 000613401OtherMISSOURI DEPARTMENT OF SOCIAL SERVICES, CHILDRENS DIVISION
CCCJS A11182OtherAMERICAN COLLEGE OF CERTIFIED FORENSIC COUNSELORS
ICAADC 597OtherTHE INTERNATIONAL CERTIFICATION & RECIPROCITY CONSORTIUM / A & D ABUSE, INC.
MO1253-10266OtherMO STATE CERTIFIED INTENMSIVE OUTPATIENT ALCOHOL & DRUG REHABILITATION CLINIC
MOREACT R-319OtherMO STATE CERTIFIED REQUIRED EDUCATIONAL ASSESSMENT AND COMMUNITY TREATMENT
MOCASAC 542OtherMISSOURI SUBSTANCE ABUSE PROFESSIONAL CREDENTIALING BOARD