Provider Demographics
NPI:1639409873
Name:CRESCENT CENTER COUNSELING
Entity Type:Organization
Organization Name:CRESCENT CENTER COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:GABEHART
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC
Authorized Official - Phone:417-588-5885
Mailing Address - Street 1:104 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-3301
Mailing Address - Country:US
Mailing Address - Phone:417-588-5885
Mailing Address - Fax:417-588-4296
Practice Address - Street 1:104 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3301
Practice Address - Country:US
Practice Address - Phone:417-588-5885
Practice Address - Fax:417-588-4296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000197194101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494879539Medicaid