Healthcare Provider Details

I. General information

NPI: 1982112819
Provider Name (Legal Business Name): ELIZABETH JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3165 MCKELVEY RD STE 200
BRIDGETON MO
63044-2550
US

IV. Provider business mailing address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3900
  • Fax:
Mailing address:
  • Phone: 314-206-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number00004535
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: