Healthcare Provider Details

I. General information

NPI: 1396750063
Provider Name (Legal Business Name): MITCHELL JAMES VON GEMMINGEN MA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LYNCH ST
SAINT LOUIS MO
63118-1818
US

IV. Provider business mailing address

2885 W BATTLEFIELD ST
SPRINGFIELD MO
65807-3952
US

V. Phone/Fax

Practice location:
  • Phone: 314-535-5600
  • Fax: 314-206-3477
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2005014249
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: