Healthcare Provider Details

I. General information

NPI: 1013676865
Provider Name (Legal Business Name): KAYLA NOELLE THEBERGE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10024 OFFICE CENTER AVE STE 100
SAINT LOUIS MO
63128-1392
US

IV. Provider business mailing address

1601 OLD SOUTH RIVER RD
SAINT CHARLES MO
63303-4120
US

V. Phone/Fax

Practice location:
  • Phone: 314-729-7050
  • Fax:
Mailing address:
  • Phone: 636-246-1210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2021046281
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: