Healthcare Provider Details

I. General information

NPI: 1912426586
Provider Name (Legal Business Name): SHAYNA PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2017
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11701 W FLORISSANT AVE
FLORISSANT MO
63033-6744
US

IV. Provider business mailing address

11701 W FLORISSANT AVE
FLORISSANT MO
63033-6744
US

V. Phone/Fax

Practice location:
  • Phone: 314-972-8132
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2017010560
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2021025415
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: