Healthcare Provider Details

I. General information

NPI: 1265763569
Provider Name (Legal Business Name): GENESIS CHRISTIAN COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2190 S MASON RD STE 306
SAINT LOUIS MO
63131-1637
US

IV. Provider business mailing address

2190 S MASON RD STE 306
SAINT LOUIS MO
63131-1637
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-7335
  • Fax: 314-821-7446
Mailing address:
  • Phone: 314-821-7335
  • Fax: 314-821-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC0980816
License Number StateMO

VIII. Authorized Official

Name: DAVID ANDREW HOLDEN
Title or Position: MEMBER
Credential: LPC
Phone: 314-821-7335