Healthcare Provider Details

I. General information

NPI: 1902463029
Provider Name (Legal Business Name): WELLHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6113 RIDGE AVE
SAINT LOUIS MO
63133-2616
US

IV. Provider business mailing address

716 FRANCIS PL
SAINT LOUIS MO
63105-2462
US

V. Phone/Fax

Practice location:
  • Phone: 314-925-7525
  • Fax: 314-658-9374
Mailing address:
  • Phone: 314-632-6206
  • Fax: 314-658-9374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ROBERT CORMIER
Title or Position: CLINIC DIRECTOR
Credential: PHD, BCBA, LBA
Phone: 314-925-7525