Healthcare Provider Details

I. General information

NPI: 1194140756
Provider Name (Legal Business Name): EMERGENCE PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2014
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 THORNWOOD DR
SAINT LOUIS MO
63124-1227
US

IV. Provider business mailing address

8000 BONHOMME AVE STE 206
CLAYTON MO
63105-3515
US

V. Phone/Fax

Practice location:
  • Phone: 314-800-4215
  • Fax:
Mailing address:
  • Phone: 314-800-4215
  • Fax: 949-863-5179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLC1378481
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JAMECA WOODY-COOPER
Title or Position: COUNSELING PSYCHOLOGIST
Credential: PHD
Phone: 314-800-4215