Provider Demographics
NPI:1639633290
Name:SYNERGY EXECUTIVE, LLC
Entity Type:Organization
Organization Name:SYNERGY EXECUTIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:417-551-9192
Mailing Address - Street 1:2608 SMYRNA ROAD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721
Mailing Address - Country:US
Mailing Address - Phone:417-838-0894
Mailing Address - Fax:
Practice Address - Street 1:2608 SMYRNA RD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-7674
Practice Address - Country:US
Practice Address - Phone:417-812-4440
Practice Address - Fax:417-208-5880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-29
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2849OtherDEPT. OF MENTAL HEALTH/DBH