Provider Demographics
NPI:1801015342
Name:PSYCARE OF CALLAWAY COUNTY, LLC
Entity Type:Organization
Organization Name:PSYCARE OF CALLAWAY COUNTY, LLC
Other - Org Name:PSYCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBRODIE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:573-220-8366
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-0605
Mailing Address - Country:US
Mailing Address - Phone:573-642-0087
Mailing Address - Fax:
Practice Address - Street 1:601 W NIFONG, BLDG. 5A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203
Practice Address - Country:US
Practice Address - Phone:573-220-2366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030184831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498394212Medicaid
MO000014534Medicare ID - Type Unspecified