Provider Demographics
NPI:1578599973
Name:LUMOS, THERESA L (LPC)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:L
Last Name:LUMOS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 DILLON OUTER RD
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-7854
Mailing Address - Country:US
Mailing Address - Phone:573-382-6247
Mailing Address - Fax:
Practice Address - Street 1:11000 DILLON OUTER RD
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-7854
Practice Address - Country:US
Practice Address - Phone:573-382-6247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003032047101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499142602Medicaid