Healthcare Provider Details

I. General information

NPI: 1568376572
Provider Name (Legal Business Name): POLARIS WELLNESS AND HEALING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 GREENSLEEVES DR
FENTON MO
63026-3343
US

IV. Provider business mailing address

655 GREENSLEEVES DR
FENTON MO
63026-3343
US

V. Phone/Fax

Practice location:
  • Phone: 636-359-3454
  • Fax:
Mailing address:
  • Phone: 636-359-3454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGEL M COLEMAN
Title or Position: OWNER
Credential: LPC
Phone: 636-359-3454