Healthcare Provider Details

I. General information

NPI: 1104972553
Provider Name (Legal Business Name): NICHOLAS CHANDLER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3309 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63139-1101
US

IV. Provider business mailing address

7917 AMHERST AVE
SAINT LOUIS MO
63130-3602
US

V. Phone/Fax

Practice location:
  • Phone: 314-534-9350
  • Fax:
Mailing address:
  • Phone: 314-862-4860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002481
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: