Healthcare Provider Details

I. General information

NPI: 1891571865
Provider Name (Legal Business Name): KIERRA CONDOLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 DELMAR BLVD STE B300
SAINT LOUIS MO
63112-3078
US

IV. Provider business mailing address

407 KENNER AVE
KENNER LA
70062-7134
US

V. Phone/Fax

Practice location:
  • Phone: 314-469-4908
  • Fax:
Mailing address:
  • Phone: 504-669-9530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: