Healthcare Provider Details

I. General information

NPI: 1790072262
Provider Name (Legal Business Name): BJC BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 07/06/2011
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

3165 MCKELVEY RD STE 200
BRIDGETON MO
63044-2550
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: ANGIE NICOLE DOCKINS
Title or Position: CASE MANAGER
Credential: M.ED
Phone: 314-308-2508