Healthcare Provider Details

I. General information

NPI: 1740701374
Provider Name (Legal Business Name): ALICIA D BUCK HALL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 11/16/2021
Certification Date: 07/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 N EUCLID AVE STE 300
SAINT LOUIS MO
63108-1609
US

IV. Provider business mailing address

449 N EUCLID AVE
SAINT LOUIS MO
63108-1642
US

V. Phone/Fax

Practice location:
  • Phone: 314-475-8532
  • Fax:
Mailing address:
  • Phone: 314-475-8532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2017042558
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2017042558
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: