Provider Demographics
NPI:1457771677
Name:DYNAMIC COUNSELING AND CONSULTATION SERVICES
Entity Type:Organization
Organization Name:DYNAMIC COUNSELING AND CONSULTATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-719-6263
Mailing Address - Street 1:3600 S WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:314-719-6263
Mailing Address - Fax:800-335-4761
Practice Address - Street 1:3600 S WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:314-719-6263
Practice Address - Fax:800-335-4761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-27
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030321961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497312108Medicaid