Healthcare Provider Details

I. General information

NPI: 1356795090
Provider Name (Legal Business Name): BJC BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3309 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63139-1101
US

IV. Provider business mailing address

3309 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63139-1101
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3800
  • Fax:
Mailing address:
  • Phone: 314-206-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number267-7258
License Number StateMO

VIII. Authorized Official

Name: ANGELA MARTIN-DAVIS
Title or Position: PRESIDENT
Credential:
Phone: 314-206-3712