Healthcare Provider Details

I. General information

NPI: 1922016146
Provider Name (Legal Business Name): FAMILY SUPPORT NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7514 BIG BEND BLVD
SAINT LOUIS MO
63119-2104
US

IV. Provider business mailing address

7514 BIG BEND BLVD
SAINT LOUIS MO
63119-2104
US

V. Phone/Fax

Practice location:
  • Phone: 314-644-5055
  • Fax: 314-644-5057
Mailing address:
  • Phone: 314-644-5055
  • Fax: 314-644-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. VINCENT J. MARINO
Title or Position: ASSOCIATE EXECUTIVE DIRECTOR
Credential: MSW
Phone: 314-644-5055