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4900 Highway D Defiance MO 63341-1314 | |
(630) 653-1717 | |
(630) 653-1025 |
Full Name | |
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Speciality | Counselor |
Location | 4900 Highway D, Defiance, Missouri |
Authorized Official Name and Position | Heather Gandy (CHIEF FINANCIAL OFFICER) |
Authorized Official Contact | 6306531717 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
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2100 Manchester Rd Suite 1510 Wheaton IL 60187-4579 Ph: (630) 653-1717 | 4900 Highway D Defiance MO 63341-1314 Ph: (630) 653-1717 |
NPI Number | 1649227455 |
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Provider Enumeration Date | 05/27/2006 |
Last Update Date | 08/22/2020 |
Identifier | Type | State | Issuer |
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1649227455 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
101Y00000X | Counselor | 2005041410 (Missouri) | Primary |