Provider Demographics
NPI:1770649451
Name:PALMER, THERESA ANGELA (LPC)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANGELA
Last Name:PALMER
Suffix:
Gender:F
Credentials:LPC
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 104
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-0104
Mailing Address - Country:US
Mailing Address - Phone:636-586-4655
Mailing Address - Fax:636-243-0782
Practice Address - Street 1:605 S 2ND ST
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-2010
Practice Address - Country:US
Practice Address - Phone:636-586-4655
Practice Address - Fax:636-243-0782
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCS000583101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497863100Medicaid