Healthcare Provider Details

I. General information

NPI: 1578578852
Provider Name (Legal Business Name): KIRA JENNELLE GILL BS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 03/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 W RUE DE LA BANQUE APT I
CREVE COEUR MO
63141-5111
US

IV. Provider business mailing address

995 W RUE DE LA BANQUE APT I
SAINT LOUIS MO
63141-5111
US

V. Phone/Fax

Practice location:
  • Phone: 314-620-3511
  • Fax:
Mailing address:
  • Phone: 314-620-3511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2015000707
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: