Healthcare Provider Details

I. General information

NPI: 1104440072
Provider Name (Legal Business Name): BEYOND VISION MENTAL HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 LONG RD STE 123
CHESTERFIELD MO
63005-1282
US

IV. Provider business mailing address

331 N NEW BALLAS RD
SAINT LOUIS MO
63141-5502
US

V. Phone/Fax

Practice location:
  • Phone: 818-308-4388
  • Fax: 855-954-4533
Mailing address:
  • Phone: 818-308-4388
  • Fax: 855-954-4533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. D. MARK FASSETT II
Title or Position: COO
Credential:
Phone: 917-822-9002