Healthcare Provider Details

I. General information

NPI: 1336452580
Provider Name (Legal Business Name): BTA BEHAVIORAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9167 W FLORISSANT AVE
SAINT LOUIS MO
63136-1420
US

IV. Provider business mailing address

PO BOX 703
BRIDGETON MO
63044-0703
US

V. Phone/Fax

Practice location:
  • Phone: 314-574-4081
  • Fax: 314-524-3804
Mailing address:
  • Phone: 314-574-4081
  • Fax: 314-524-3804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateMO

VIII. Authorized Official

Name: MR. LEONARD E. BRADLEY
Title or Position: PROGRAM DIRECTOR
Credential: MSE, CCDP-D, ICCDP-D
Phone: 314-574-4081