Healthcare Provider Details

I. General information

NPI: 1568834489
Provider Name (Legal Business Name): ANTONIO ROBINSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N. GORE GREAT CIRCLE
SAINT LOUIS MO
63119
US

IV. Provider business mailing address

11 WILLIAMS BLVD
SAINT LOUIS MO
63135-1040
US

V. Phone/Fax

Practice location:
  • Phone: 314-968-2060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: