Healthcare Provider Details

I. General information

NPI: 1831873504
Provider Name (Legal Business Name): AMANDA L WOOLLARD MA LPC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 UNION RD STE 225
SAINT LOUIS MO
63129-1093
US

IV. Provider business mailing address

8539 TALMA CT
AFFTON MO
63123-3633
US

V. Phone/Fax

Practice location:
  • Phone: 314-730-6787
  • Fax: 314-730-6585
Mailing address:
  • Phone: 618-604-8326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: AMANDA L WOOLLARD
Title or Position: OWNER
Credential: LPC
Phone: 618-604-8326