Healthcare Provider Details

I. General information

NPI: 1689131880
Provider Name (Legal Business Name): COMMUNITY CONNECTIONS STL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2019
Last Update Date: 02/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 STAGE COACH LANDING DR
SAINT PETERS MO
63376-4210
US

IV. Provider business mailing address

225 STAGE COACH LANDING DR
SAINT PETERS MO
63376-4210
US

V. Phone/Fax

Practice location:
  • Phone: 765-265-4524
  • Fax:
Mailing address:
  • Phone: 765-265-4524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHERYL M WHITE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 765-265-4524