Healthcare Provider Details

I. General information

NPI: 1730659376
Provider Name (Legal Business Name): GREAT CIRCLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N GORE AVE
SAINT LOUIS MO
63119-1600
US

IV. Provider business mailing address

PO BOX 189
SAINT JAMES MO
65559-0189
US

V. Phone/Fax

Practice location:
  • Phone: 314-968-2060
  • Fax: 314-968-8308
Mailing address:
  • Phone: 573-265-3251
  • Fax: 573-265-5370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name: DAWN RENEE KLIETHERMES
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 573-303-7219