MEDICARE: THERESA WISS LCSW LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1578498960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERESA WISS LCSW LLC

Provider Business Mailing Address
First Line	:	6925 COLUMBIA AVE
Second Line	:
City	:	UNIVERSITY CITY
State	:	MO
Zip	:	63130-3127
Country	:	US
Telephone Number	:	860-324-3581
Fax Number	:	860-324-3581

Provider Business Practice Location Address
First Line	:	7200 MANCHESTER RD
Second Line	:
City	:	MAPLEWOOD
State	:	MO
Zip	:	63143-2403
Country	:	US
Telephone Number	:	860-324-3581
Fax Number	:

Authorized Official
Title or Position	:	OWNER/LCSW
Name	:	THERESA WISS
Credential	:	LCSW
Telephone Number	:	860-324-3581

Provider Enumeration Date	:	06/16/2026
Last Update Date	:	06/25/2026

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