Southern Light Residential

NPI #1801312459 in Bolivar, Missouri

Provider Information

NPI Number: 1801312459
Entity Type: Organization
Organization Name: Southern Light Residential
Primary Specialty: Counselor - Professional
Enumeration Date: Aug 16, 2017
Last Updated: Aug 16, 2017

Practice Location

Address: 1211 E BROADWAY ST
City: Bolivar
State: Missouri
ZIP Code: 65613-2952
Phone: (417) 850-4555

Authorized Official

Name: CINDY DRAKE
Title: ADMIN DIRECTOR
Phone: (417) 850-4555

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Counselor - Professional — Professional	101YP2500X	Primary

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