Healthcare Provider Details

I. General information

NPI: 1588088538
Provider Name (Legal Business Name): EDWARD FLYNN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2014
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5261 DELMAR BLVD SUITE 214
SAINT LOUIS MO
63108-1063
US

IV. Provider business mailing address

4024 WYOMING ST
SAINT LOUIS MO
63116-3920
US

V. Phone/Fax

Practice location:
  • Phone: 314-497-6617
  • Fax: 314-454-5715
Mailing address:
  • Phone: 314-378-0290
  • Fax: 314-454-5715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2014000915
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: