Healthcare Provider Details

I. General information

NPI: 1245162064
Provider Name (Legal Business Name): ELLEN MARIE KOMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 CLARKSON RD STE 102
ELLISVILLE MO
63011-2497
US

IV. Provider business mailing address

469 MELANIE MEADOWS LN
BALLWIN MO
63021-6337
US

V. Phone/Fax

Practice location:
  • Phone: 636-256-0600
  • Fax:
Mailing address:
  • Phone: 636-579-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2026023975
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: