Healthcare Provider Details

I. General information

NPI: 1063374270
Provider Name (Legal Business Name): KIPP ST. LOUIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2647 OHIO AVE
SAINT LOUIS MO
63118-1533
US

IV. Provider business mailing address

2647 OHIO AVE
SAINT LOUIS MO
63118-1533
US

V. Phone/Fax

Practice location:
  • Phone: 314-349-1388
  • Fax:
Mailing address:
  • Phone: 314-349-1388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: JULIAN VIZITEI
Title or Position: MEDICAID CORDINATOR
Credential:
Phone: 573-489-1662