Healthcare Provider Details

I. General information

NPI: 1780454785
Provider Name (Legal Business Name): PEARL TATE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 BRIDGELAND DR STE E
BRIDGETON MO
63044-2605
US

IV. Provider business mailing address

605 CLARA AVE APT 302
SAINT LOUIS MO
63112-1934
US

V. Phone/Fax

Practice location:
  • Phone: 314-722-4117
  • Fax:
Mailing address:
  • Phone: 641-871-0541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2023002998
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: