Provider Demographics
NPI:1891381216
Name:COUNTRYSIDE COUNSELING LLC
Entity Type:Organization
Organization Name:COUNTRYSIDE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:417-597-4685
Mailing Address - Street 1:3036 W COUNTRYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-3936
Mailing Address - Country:US
Mailing Address - Phone:417-597-4685
Mailing Address - Fax:855-437-0772
Practice Address - Street 1:313 SOUTH AVE STE 405
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2255
Practice Address - Country:US
Practice Address - Phone:417-597-4685
Practice Address - Fax:855-437-0772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-19
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1245796440Medicaid