Healthcare Provider Details

I. General information

NPI: 1881723773
Provider Name (Legal Business Name): TOFBC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LAKE SAINT LOUIS BLVD SUITE 261
LAKE SAINT LOUIS MO
63367-1340
US

IV. Provider business mailing address

1000 LAKE SAINT LOUIS BLVD SUITE 261
LAKE SAINT LOUIS MO
63367-1340
US

V. Phone/Fax

Practice location:
  • Phone: 636-561-0268
  • Fax: 636-625-1580
Mailing address:
  • Phone: 636-561-0268
  • Fax: 636-625-1580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2001020554
License Number StateMO

VIII. Authorized Official

Name: MRS. VICKY LYNN GLASS
Title or Position: THERAPIST, MEMBER OF TOFBC, LLC
Credential: L.C.S.W.
Phone: 636-561-0268