Healthcare Provider Details

I. General information

NPI: 1750122552
Provider Name (Legal Business Name): WISDOM TREE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 LIGGETT DR
SAINT LOUIS MO
63126-1341
US

IV. Provider business mailing address

5850 MACKLIND AVE # 1089
SAINT LOUIS MO
63109-3569
US

V. Phone/Fax

Practice location:
  • Phone: 314-282-4888
  • 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: STACEY STEFANSKI
Title or Position: OWNER
Credential:
Phone: 314-282-4888