MEDICARE: TOFBC, 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	1041C0700X	Clinical Social Worker	2001020554	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	152189	OTHER	MO	ANTHEM BCBS ID#

General Provider Information

NPI Number	:	1881723773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOFBC, LLC

Provider Business Mailing Address
First Line	:	1000 LAKE SAINT LOUIS BLVD
Second Line	:	SUITE 261
City	:	LAKE SAINT LOUIS
State	:	MO
Zip	:	63367-1340
Country	:	US
Telephone Number	:	636-561-0268
Fax Number	:	636-625-1580

Provider Business Practice Location Address
First Line	:	1000 LAKE SAINT LOUIS BLVD
Second Line	:	SUITE 261
City	:	LAKE SAINT LOUIS
State	:	MO
Zip	:	63367-1340
Country	:	US
Telephone Number	:	636-561-0268
Fax Number	:	636-625-1580

Authorized Official
Title or Position	:	THERAPIST, MEMBER OF TOFBC, LLC
Name	:	MRS. VICKY LYNN GLASS
Credential	:	L.C.S.W.
Telephone Number	:	636-561-0268

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	08/22/2020

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Directions to “TOFBC, LLC ” Practice Location

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