Healthcare Provider Details

I. General information

NPI: 1467900340
Provider Name (Legal Business Name): THE COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8936 GOODFELLOW BLVD
SAINT LOUIS MO
63147-1433
US

IV. Provider business mailing address

8936 GOODFELLOW BLVD
SAINT LOUIS MO
63147-1433
US

V. Phone/Fax

Practice location:
  • Phone: 314-580-3029
  • Fax:
Mailing address:
  • Phone: 314-580-3029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number225C00000X
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number305S00000X
License Number StateMO

VIII. Authorized Official

Name: DR. MARVIN SHELTON
Title or Position: CEO
Credential: ED.S, ED.D, RSAP
Phone: 314-580-3029