Healthcare Provider Details

I. General information

NPI: 1053021865
Provider Name (Legal Business Name): CONCORDANCE ACADEMY OF LEADERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 BORMAN CT
SAINT LOUIS MO
63146-4126
US

IV. Provider business mailing address

6 CITYPLACE DR STE 522
SAINT LOUIS MO
63141-7209
US

V. Phone/Fax

Practice location:
  • Phone: 314-396-6001
  • Fax:
Mailing address:
  • Phone: 314-396-6004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MR. CLINTON LEE HOLMES JR.
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 314-396-6004