Healthcare Provider Details

I. General information

NPI: 1164593729
Provider Name (Legal Business Name): JOHN S MCCONAGHY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 MORGANFORD RD ST. LOUIS ACADEMY
SAINT LOUIS MO
63116-1409
US

IV. Provider business mailing address

7167 WASHINGTON AVENUE
ST. LOUIS MO
63130
US

V. Phone/Fax

Practice location:
  • Phone: 314-481-5100
  • Fax: 314-259-1147
Mailing address:
  • Phone: 314-727-1939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2001004874
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: