Healthcare Provider Details

I. General information

NPI: 1639396534
Provider Name (Legal Business Name): LISA M PANICOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 KEATON CORPORATE PKWY STE 101
O FALLON MO
63368-8636
US

IV. Provider business mailing address

6626 MARDEL AVE
SAINT LOUIS MO
63109-1226
US

V. Phone/Fax

Practice location:
  • Phone: 314-210-2310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2006036530
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: