Healthcare Provider Details

I. General information

NPI: 1053721290
Provider Name (Legal Business Name): ANITA B POLZIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANITA B MERSHON

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4066 DUNNICA AVE
SAINT LOUIS MO
63116-3510
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 636-224-1700
  • Fax: 314-535-5917
Mailing address:
  • Phone: 636-246-1210
  • Fax: 636-246-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5961
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2022022871
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: