Healthcare Provider Details

I. General information

NPI: 1124609656
Provider Name (Legal Business Name): ELIZABETH RASTBERGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3284 IVANHOE AVE STE E
SAINT LOUIS MO
63139-2246
US

IV. Provider business mailing address

3284 IVANHOE AVE STE E
SAINT LOUIS MO
63139-2246
US

V. Phone/Fax

Practice location:
  • Phone: 314-675-0056
  • Fax:
Mailing address:
  • Phone: 314-675-0056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2021032461
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: