Healthcare Provider Details

I. General information

NPI: 1558941286
Provider Name (Legal Business Name): BRACKS FAMILY COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10805 SUNSET OFFICE DR STE 201
SAINT LOUIS MO
63127-1026
US

IV. Provider business mailing address

10805 SUNSET OFFICE DR STE 210
SAINT LOUIS MO
63127-1026
US

V. Phone/Fax

Practice location:
  • Phone: 402-975-5650
  • Fax:
Mailing address:
  • Phone: 402-975-5650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. NATHANIEL TYLER BRACK
Title or Position: OWNER
Credential: LPC
Phone: 314-626-0962