Healthcare Provider Details

I. General information

NPI: 1750616199
Provider Name (Legal Business Name): MY PLACE TOO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 10/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 CLARKE ST
DE SOTO MO
63020-2709
US

IV. Provider business mailing address

23 N 6TH ST
FESTUS MO
63028-1301
US

V. Phone/Fax

Practice location:
  • Phone: 636-586-7871
  • Fax:
Mailing address:
  • Phone: 636-933-1793
  • Fax: 636-933-6446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPENDING
License Number StateMO

VIII. Authorized Official

Name: MARY L CASEY
Title or Position: ADMINISTRATOR
Credential: LPN, LNHA
Phone: 636-526-7871