Provider Demographics
NPI:1730644592
Name:WELCH, THERESA (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WELCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-0853
Mailing Address - Country:US
Mailing Address - Phone:636-795-0115
Mailing Address - Fax:
Practice Address - Street 1:1191 STATE HWY KK
Practice Address - Street 2:SUITE 101
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065
Practice Address - Country:US
Practice Address - Phone:573-302-7241
Practice Address - Fax:573-302-7239
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0029811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical