Healthcare Provider Details

I. General information

NPI: 1700155595
Provider Name (Legal Business Name): HOUSE OF PRAYER CHRISTIAN ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 N PARK DR
EAST SAINT LOUIS IL
62204-2121
US

IV. Provider business mailing address

5501 N PARK DR
EAST SAINT LOUIS IL
62204-2121
US

V. Phone/Fax

Practice location:
  • Phone: 618-274-3850
  • Fax:
Mailing address:
  • Phone: 618-274-3850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTHONY DEWAYNE PETTIFORD
Title or Position: CEO
Credential:
Phone: 618-274-3850