Healthcare Provider Details

I. General information

NPI: 1114268935
Provider Name (Legal Business Name): BJC BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2013
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 MAPLE ST
FARMINGTON MO
63640-1955
US

IV. Provider business mailing address

1085 MAPLE ST
FARMINGTON MO
63640-1955
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-5353
  • Fax:
Mailing address:
  • Phone: 573-756-5353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: ANGELA MARTIN-DAVIS
Title or Position: PRESIDENT
Credential:
Phone: 314-206-3712