Healthcare Provider Details

I. General information

NPI: 1891448981
Provider Name (Legal Business Name): TONY DEON GILLON JR. M.ED., LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 01/31/2022
Certification Date: 01/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5319 SHAW AVE
SAINT LOUIS MO
63110-3023
US

IV. Provider business mailing address

5319 SHAW AVE
SAINT LOUIS MO
63110-3023
US

V. Phone/Fax

Practice location:
  • Phone: 314-378-3433
  • Fax:
Mailing address:
  • Phone: 314-378-3433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2018040871
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number2018040871
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2018040871
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: