Healthcare Provider Details

I. General information

NPI: 1093531295
Provider Name (Legal Business Name): UNLOCKING POTENTIAL WITHIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7110 OAKLAND AVE STE 105
RICHMOND HEIGHTS MO
63117-1870
US

IV. Provider business mailing address

1176 HILLARD RD
SAINT LOUIS MO
63122-3256
US

V. Phone/Fax

Practice location:
  • Phone: 314-391-5465
  • Fax: 314-227-9327
Mailing address:
  • Phone: 352-359-1482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREW WISLOCKI
Title or Position: OWNER
Credential: PHD
Phone: 352-359-1482