Provider Demographics
NPI:1922352012
Name:SPRING GROVE COUNSELING
Entity Type:Organization
Organization Name:SPRING GROVE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:WIEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LCSW
Authorized Official - Phone:573-635-8299
Mailing Address - Street 1:211 A OSCAR DRIVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5167
Mailing Address - Country:US
Mailing Address - Phone:573-635-8299
Mailing Address - Fax:573-635-4629
Practice Address - Street 1:211 A OSCAR DRIVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5167
Practice Address - Country:US
Practice Address - Phone:573-635-8299
Practice Address - Fax:573-635-4629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001621101Y00000X
MO002100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493361109Medicaid