Healthcare Provider Details

I. General information

NPI: 1154070175
Provider Name (Legal Business Name): GREENLEAF THERACARE IOP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10199 WOODFIELD LN
SAINT LOUIS MO
63132-2922
US

IV. Provider business mailing address

10199 WOODFIELD LN
SAINT LOUIS MO
63132-2922
US

V. Phone/Fax

Practice location:
  • Phone: 314-504-0404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ALEXANDER SHLAFSHTEYN
Title or Position: MEMBER
Credential:
Phone: 314-504-0404