Healthcare Provider Details

I. General information

NPI: 1942778360
Provider Name (Legal Business Name): MELYNDA HEIENICKLE BSED, MC, CSC, PLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2018
Last Update Date: 11/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 WOODSTONE DR STE 112
SAINT CHARLES MO
63304-6872
US

IV. Provider business mailing address

3150 LA BARON LN
SAINT CHARLES MO
63303-6359
US

V. Phone/Fax

Practice location:
  • Phone: 636-362-4551
  • Fax:
Mailing address:
  • Phone: 314-458-5233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2018036494
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: