Healthcare Provider Details

I. General information

NPI: 1376929786
Provider Name (Legal Business Name): MICKEY OWEN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-7236
  • Fax: 314-525-1886
Mailing address:
  • Phone: 314-525-7236
  • Fax: 314-525-1886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number003410
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: