Healthcare Provider Details

I. General information

NPI: 1407571144
Provider Name (Legal Business Name): DEBORAH MICHELLE BENNETT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 WOODLAKE DR STE 200
CHESTERFIELD MO
63017-5740
US

IV. Provider business mailing address

1585 WOODLAKE DR STE 200
CHESTERFIELD MO
63017-5740
US

V. Phone/Fax

Practice location:
  • Phone: 314-887-7579
  • Fax: 314-887-7295
Mailing address:
  • Phone: 314-887-7579
  • Fax: 314-887-7295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2018011484
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: