Healthcare Provider Details

I. General information

NPI: 1306319694
Provider Name (Legal Business Name): SAMUEL BEARER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6780 SOUTHWEST AVE STE 2A
SAINT LOUIS MO
63143-2624
US

IV. Provider business mailing address

824 SANDERS PL
SAINT LOUIS MO
63126-1224
US

V. Phone/Fax

Practice location:
  • Phone: 617-379-0496
  • Fax:
Mailing address:
  • Phone: 617-379-0496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC.LH.70074588
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMHC.LH.70074588
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2017028441
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2017028441
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: