Healthcare Provider Details

I. General information

NPI: 1184413114
Provider Name (Legal Business Name): MIDDLE PATH WELLNESS COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 06/22/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 EXECUTIVE DR STE 205
SAINT CHARLES MO
63303-5606
US

IV. Provider business mailing address

2451 EXECUTIVE DR STE 205
SAINT CHARLES MO
63303-5606
US

V. Phone/Fax

Practice location:
  • Phone: 314-375-6599
  • Fax:
Mailing address:
  • Phone: 314-375-6599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MACKENZIE LESTER
Title or Position: OWNER
Credential: LCSW
Phone: 314-375-6599