Basic Information
| Provider Information | |||||||||
| NPI: | 1861597650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UNDERWOOD | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 S SILVER SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637037536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733341100 | ||||||||
| FaxNumber: | 5733348819 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MARBLE HILL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732381127 | ||||||||
| FaxNumber: | 5732381171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 000254 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 19616 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER |