Provider Demographics
NPI:1659421931
Name:EAGLE CREST COUNSELING CENTER, INC.
Entity Type:Organization
Organization Name:EAGLE CREST COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-862-8282
Mailing Address - Street 1:636 W REPUBLIC RD STE G100
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5811
Mailing Address - Country:US
Mailing Address - Phone:417-862-8282
Mailing Address - Fax:417-862-8805
Practice Address - Street 1:636 W REPUBLIC RD STE F100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5810
Practice Address - Country:US
Practice Address - Phone:417-862-8282
Practice Address - Fax:417-862-8805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500792502Medicaid
MO500792502Medicaid