Healthcare Provider Details

I. General information

NPI: 1154788735
Provider Name (Legal Business Name): ELLEN WARREN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

IV. Provider business mailing address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-5190
  • Fax:
Mailing address:
  • Phone: 314-353-5190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2015040070
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: