Healthcare Provider Details

I. General information

NPI: 1013930403
Provider Name (Legal Business Name): MILDRED ELIZABETH FORTUNE-GILPIN MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 GRAHAM RD
FLORISSANT MO
63031-8077
US

IV. Provider business mailing address

1150 GRAHAM RD STE 102
FLORISSANT MO
63031-8077
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3900
  • Fax: 314-206-3992
Mailing address:
  • Phone: 314-206-3900
  • Fax: 314-206-3992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2002014992
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: