Healthcare Provider Details

I. General information

NPI: 1639350614
Provider Name (Legal Business Name): PROVIDENT COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 CHIPPEWA ST SUITE 150
SAINT LOUIS MO
63109-4110
US

IV. Provider business mailing address

2650 OLIVE ST
SAINT LOUIS MO
63103-1424
US

V. Phone/Fax

Practice location:
  • Phone: 314-898-0101
  • Fax: 314-645-0026
Mailing address:
  • Phone: 314-371-6500
  • Fax: 314-371-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN BUESCHER
Title or Position: CEO
Credential:
Phone: 314-371-6500