Healthcare Provider Details

I. General information

NPI: 1891485371
Provider Name (Legal Business Name): MRS. BETHANY NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 EAGER RD
SAINT LOUIS MO
63144-1405
US

IV. Provider business mailing address

3309 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63139-1101
US

V. Phone/Fax

Practice location:
  • Phone: 314-308-4625
  • Fax:
Mailing address:
  • Phone: 314-206-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2017013161
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2017013161
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: