Healthcare Provider Details

I. General information

NPI: 1235775248
Provider Name (Legal Business Name): NATIONAL MENTOR SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11872 WESTLINE INDUSTRIAL DR STE 180
SAINT LOUIS MO
63146-3331
US

IV. Provider business mailing address

6067 MEXICO RD
SAINT PETERS MO
63376-1648
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-7944
  • Fax:
Mailing address:
  • Phone: 636-685-0804
  • Fax: 636-685-0805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MORGAN KEENCE
Title or Position: BCBA
Credential:
Phone: 314-991-7944