Healthcare Provider Details

I. General information

NPI: 1164515250
Provider Name (Legal Business Name): SONYA MARIA HERRON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9167 W FLORISSANT AVE
SAINT LOUIS MO
63136-1420
US

IV. Provider business mailing address

1330 ILLINI DR
O FALLON IL
62269-3550
US

V. Phone/Fax

Practice location:
  • Phone: 314-521-7900
  • Fax: 314-521-2786
Mailing address:
  • Phone: 314-521-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2000165882
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: