Healthcare Provider Details

I. General information

NPI: 1760053797
Provider Name (Legal Business Name): LIALA SLAISE MS, CRC, LCPC, CEAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12747 OLIVE BLVD STE 300
SAINT LOUIS MO
63141-6269
US

IV. Provider business mailing address

1233 TRAILWOOD CT
O FALLON IL
62269-3129
US

V. Phone/Fax

Practice location:
  • Phone: 314-872-2116
  • Fax:
Mailing address:
  • Phone: 618-960-8126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.013232
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: