Healthcare Provider Details

I. General information

NPI: 1285764324
Provider Name (Legal Business Name): MERCY FAMILY THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 05/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 EXECUTIVE PARKWAY DR
CREVE COEUR MO
63141-6302
US

IV. Provider business mailing address

970 EXECUTIVE PARKWAY DR
CREVE COEUR MO
63141-6302
US

V. Phone/Fax

Practice location:
  • Phone: 314-628-6550
  • Fax:
Mailing address:
  • Phone: 314-628-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY A. JOHNSTON
Title or Position: PRESIDENT, MERCY HOSPITAL ST. LOUIS
Credential:
Phone: 314-251-1932