Provider Demographics
NPI:1417011313
Name:DEFIBAUGH, JOANIE M (LCSW)
Entity Type:Individual
Prefix:
First Name:JOANIE
Middle Name:M
Last Name:DEFIBAUGH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JOANIE
Other - Middle Name:M
Other - Last Name:TIETJENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MO
Mailing Address - Zip Code:65281-0069
Mailing Address - Country:US
Mailing Address - Phone:573-548-3033
Mailing Address - Fax:
Practice Address - Street 1:107 E HARRISON ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:MO
Practice Address - Zip Code:65236-1267
Practice Address - Country:US
Practice Address - Phone:573-548-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050276821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497481705Medicaid