Healthcare Provider Details

I. General information

NPI: 1194359729
Provider Name (Legal Business Name): SUSAN GARTENBERG LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 BONHOMME AVE STE 406
SAINT LOUIS MO
63105-3515
US

IV. Provider business mailing address

7924 TEASDALE AVE
SAINT LOUIS MO
63130-3815
US

V. Phone/Fax

Practice location:
  • Phone: 314-532-7533
  • Fax:
Mailing address:
  • Phone: 314-532-7533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2011013939
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: