Healthcare Provider Details

I. General information

NPI: 1437751625
Provider Name (Legal Business Name): EVA SEDJO LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/03/2024
Certification Date: 11/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD STE 1250
RICHMOND HEIGHTS MO
63117-1263
US

IV. Provider business mailing address

300 45TH ST S
FARGO ND
58103
US

V. Phone/Fax

Practice location:
  • Phone: 636-939-2550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2021043061
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2021043061
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: