Provider Demographics
NPI:1760736326
Name:CROSSROADS COUNSELING SERVICES
Entity Type:Organization
Organization Name:CROSSROADS COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:FLEETWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PLPC
Authorized Official - Phone:417-926-7623
Mailing Address - Street 1:600 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-1309
Mailing Address - Country:US
Mailing Address - Phone:417-926-7623
Mailing Address - Fax:
Practice Address - Street 1:600 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1309
Practice Address - Country:US
Practice Address - Phone:417-926-7623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1982973236Medicaid