Healthcare Provider Details

I. General information

NPI: 1699121475
Provider Name (Legal Business Name): COMMUNITY AND LONG-TERM CARE PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD STE 362B
SAINT LOUIS MO
63128-2178
US

IV. Provider business mailing address

10004 KENNERLY RD STE 362B
SAINT LOUIS MO
63128-2178
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-5050
  • Fax: 314-525-5072
Mailing address:
  • Phone: 314-525-5050
  • Fax: 314-525-5072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number2015002634
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2015002634
License Number StateMO

VIII. Authorized Official

Name: DR. ERNEST ALEXANDER GRAYPEL
Title or Position: OWNER
Credential: M.D.
Phone: 314-267-1075