Healthcare Provider Details

I. General information

NPI: 1790702876
Provider Name (Legal Business Name): OLA J. FORT MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS RD
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

4573 ENRIGHT AVE
SAINT LOUIS MO
63108-1707
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax: 314-894-5783
Mailing address:
  • Phone: 314-652-4100
  • Fax: 314-894-5783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002126
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: