Healthcare Provider Details

I. General information

NPI: 1275888471
Provider Name (Legal Business Name): RENEWING MINDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3394 MCKELVEY RD SUITE 116
BRIDGETON MO
63044-2531
US

IV. Provider business mailing address

PO BOX 12235
SAINT LOUIS MO
63157-0235
US

V. Phone/Fax

Practice location:
  • Phone: 314-301-9895
  • Fax: 314-209-0912
Mailing address:
  • Phone: 314-301-9895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2006036529
License Number StateMO

VIII. Authorized Official

Name: MS. WHITNEY MATHISON
Title or Position: LICENSED COUNSELOR/CEO/OWNER
Credential: LPC, NCC
Phone: 314-301-9895