Healthcare Provider Details

I. General information

NPI: 1174668289
Provider Name (Legal Business Name): INDEPENDENCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4245 FOREST PARK AVE
SAINT LOUIS MO
63108-2810
US

IV. Provider business mailing address

4245 FOREST PARK AVE
SAINT LOUIS MO
63108-2810
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-4545
  • Fax: 314-286-4542
Mailing address:
  • Phone: 314-880-5401
  • Fax: 314-880-5468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. PATRICIA HOLMES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 314-880-5415