Provider Demographics
NPI:1306164785
Name:TRINITY LIFE COUNSELING
Entity type:Organization
Organization Name:TRINITY LIFE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNGSTRUM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:417-388-9872
Mailing Address - Street 1:16262 VIXEN RD
Mailing Address - Street 2:
Mailing Address - City:STARK CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64866-7945
Mailing Address - Country:US
Mailing Address - Phone:417-388-9872
Mailing Address - Fax:888-310-7328
Practice Address - Street 1:16262 VIXEN RD
Practice Address - Street 2:
Practice Address - City:STARK CITY
Practice Address - State:MO
Practice Address - Zip Code:64866-7945
Practice Address - Country:US
Practice Address - Phone:417-388-9872
Practice Address - Fax:888-310-7328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030184041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497388108Medicaid
MA2330Medicare PIN