Healthcare Provider Details

I. General information

NPI: 1194659177
Provider Name (Legal Business Name): TILWUANA WELLS PLBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 CRAIGSHIRE DR STE 410
SAINT LOUIS MO
63146-4012
US

IV. Provider business mailing address

14623 ROUVRE DR
FLORISSANT MO
63034-2317
US

V. Phone/Fax

Practice location:
  • Phone: 314-326-4185
  • Fax:
Mailing address:
  • Phone: 314-441-1923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2026025925
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: