Healthcare Provider Details

I. General information

NPI: 1730409053
Provider Name (Legal Business Name): KATHERINE LONDON KIENTZLE MA PLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11709 OLD BALLAS RD SUITE 103
SAINT LOUIS MO
63141-7029
US

IV. Provider business mailing address

930 WINDSOR CT
WEBSTER GROVES MO
63119-3948
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-2428
  • Fax: 314-432-2222
Mailing address:
  • Phone: 314-491-7003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2009000557
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: