Healthcare Provider Details

I. General information

NPI: 1467802322
Provider Name (Legal Business Name): LIBERATE LEARNING INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N 11TH ST
SAINT LOUIS MO
63101-1015
US

IV. Provider business mailing address

3833 MCREE AVE
SAINT LOUIS MO
63110-2619
US

V. Phone/Fax

Practice location:
  • Phone: 314-690-9433
  • Fax:
Mailing address:
  • Phone: 314-690-9433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateMO

VIII. Authorized Official

Name: MR. JON-PIERRE MITCHOM
Title or Position: FOUNDER/CEO
Credential: PLPC
Phone: 314-690-9433