Healthcare Provider Details

I. General information

NPI: 1740580315
Provider Name (Legal Business Name): INTEGRATED NEUROSCIENCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11477 OLDE CABIN RD SUITE 210
SAINT LOUIS MO
63141-7130
US

IV. Provider business mailing address

11477 OLDE CABIN RD SUITE 210
SAINT LOUIS MO
63141-7130
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-2296
  • Fax: 314-997-5368
Mailing address:
  • Phone: 314-997-2296
  • Fax: 314-997-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2007012895
License Number StateMO

VIII. Authorized Official

Name: MR. JOHN PALMER CRUM
Title or Position: CLINICAL DIRECTOR
Credential: LCPC
Phone: 314-997-2296