Healthcare Provider Details

I. General information

NPI: 1841944980
Provider Name (Legal Business Name): AMYGDALA CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 02/08/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N HIGH ST STE 3
BELLEVILLE IL
62220-1436
US

IV. Provider business mailing address

110 N HIGH ST STE 3
BELLEVILLE IL
62220-1436
US

V. Phone/Fax

Practice location:
  • Phone: 314-518-7967
  • Fax:
Mailing address:
  • Phone: 314-518-7967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LINDSEY J WOLD
Title or Position: CEO
Credential:
Phone: 314-518-7967