Provider Demographics
NPI:1447231808
Name:TABLE ROCK COUNSELING, LLC
Entity Type:Organization
Organization Name:TABLE ROCK COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:DOMSCH
Authorized Official - Suffix:
Authorized Official - Credentials:ACSW, LCSW
Authorized Official - Phone:417-272-0055
Mailing Address - Street 1:67 BISHOP LN
Mailing Address - Street 2:
Mailing Address - City:KIMBERLING CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65686-9818
Mailing Address - Country:US
Mailing Address - Phone:417-230-1279
Mailing Address - Fax:417-739-1360
Practice Address - Street 1:67 BISHOP LN
Practice Address - Street 2:
Practice Address - City:KIMBERLING CITY
Practice Address - State:MO
Practice Address - Zip Code:65686-9818
Practice Address - Country:US
Practice Address - Phone:417-230-1279
Practice Address - Fax:417-739-1360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO 004512104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1144201104Medicaid
MO1144201104Medicare UPIN
MO1447231868Medicare UPIN