Healthcare Provider Details

I. General information

NPI: 1598098691
Provider Name (Legal Business Name): HYPNOTHERAPY COLLABORATIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 09/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8123 JANUARY AVE
BERKELEY MO
63134-1513
US

IV. Provider business mailing address

8123 JANUARY AVE
BERKELEY MO
63134-1513
US

V. Phone/Fax

Practice location:
  • Phone: 314-680-8179
  • Fax: 314-524-4145
Mailing address:
  • Phone: 314-680-8179
  • Fax: 314-524-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2007036005
License Number StateMO

VIII. Authorized Official

Name: JAMES B. CARROLL
Title or Position: COUNSELOR/HYPNOTHERAPIST
Credential: MA
Phone: 314-680-8179