Healthcare Provider Details

I. General information

NPI: 1710023791
Provider Name (Legal Business Name): PROVIDENT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 10/05/2022
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 OLIVE ST
SAINT LOUIS MO
63103-1424
US

IV. Provider business mailing address

2650 OLIVE ST
SAINT LOUIS MO
63103-1424
US

V. Phone/Fax

Practice location:
  • Phone: 314-371-6500
  • Fax: 314-371-1155
Mailing address:
  • Phone: 314-371-6500
  • Fax: 314-371-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KATHY S SCHLEMMER
Title or Position: RELATIONS COORDINATOR
Credential:
Phone: 314-802-2647