Provider Demographics
NPI:1548595499
Name:SHOUMAKE, MARILYN C (MSW LCSW BCD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:C
Last Name:SHOUMAKE
Suffix:
Gender:F
Credentials:MSW LCSW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-3512
Mailing Address - Country:US
Mailing Address - Phone:573-760-1365
Mailing Address - Fax:573-760-0354
Practice Address - Street 1:1580 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3512
Practice Address - Country:US
Practice Address - Phone:573-760-1365
Practice Address - Fax:573-760-0354
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080096221041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health