Provider Demographics
NPI:1538365614
Name:SAC RIVER COUNSELING, INC.
Entity type:Organization
Organization Name:SAC RIVER COUNSELING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROLLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:417-777-1476
Mailing Address - Street 1:928 E DADE 68
Mailing Address - Street 2:
Mailing Address - City:DADEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65635-8112
Mailing Address - Country:US
Mailing Address - Phone:417-777-1476
Mailing Address - Fax:
Practice Address - Street 1:406 COLLEGE ST
Practice Address - Street 2:#2
Practice Address - City:GREENFIELD
Practice Address - State:MO
Practice Address - Zip Code:65661-1346
Practice Address - Country:US
Practice Address - Phone:417-637-1476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004037100101YP2500X
MO2007003463106H00000X
MO2006033497103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497227124Medicaid