Provider Demographics
NPI:1457860819
Name:MCDONALD, THERESA M (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:888-403-1071
Mailing Address - Fax:
Practice Address - Street 1:2625 FAIRWAY DR STE E
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-4023
Practice Address - Country:US
Practice Address - Phone:573-642-3239
Practice Address - Fax:573-642-2214
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017032175104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker