Healthcare Provider Details

I. General information

NPI: 1437791068
Provider Name (Legal Business Name): PERINATAL WELLNESS INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 WOODSTONE DR STE 112
SAINT CHARLES MO
63304-6872
US

IV. Provider business mailing address

1480 WOODSTONE DR STE 112
SAINT CHARLES MO
63304-6872
US

V. Phone/Fax

Practice location:
  • Phone: 636-699-2839
  • Fax: 844-641-1015
Mailing address:
  • Phone: 636-699-2839
  • Fax: 844-641-1015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care 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
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JAMIE K BODILY
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC
Phone: 636-699-2839