Healthcare Provider Details

I. General information

NPI: 1578498960
Provider Name (Legal Business Name): THERESA WISS, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 MANCHESTER RD
MAPLEWOOD MO
63143-2403
US

IV. Provider business mailing address

6925 COLUMBIA AVE
UNIVERSITY CITY MO
63130-3127
US

V. Phone/Fax

Practice location:
  • Phone: 860-324-3581
  • Fax:
Mailing address:
  • Phone: 860-324-3581
  • Fax: 860-324-3581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: THERESA WISS
Title or Position: OWNER/LCSW
Credential: LCSW
Phone: 860-324-3581