Healthcare Provider Details

I. General information

NPI: 1528510864
Provider Name (Legal Business Name): WILLIE STREETER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4144 LINDELL BLVD STE 200
SAINT LOUIS MO
63108-2932
US

IV. Provider business mailing address

4144 LINDELL BLVD STE 200
SAINT LOUIS MO
63108-2932
US

V. Phone/Fax

Practice location:
  • Phone: 314-413-6838
  • Fax:
Mailing address:
  • Phone: 314-413-6838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: