Healthcare Provider Details

I. General information

NPI: 1639007750
Provider Name (Legal Business Name): KEIRA LYNN FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SAINT PETERS CENTRE BLVD STE B
SAINT PETERS MO
63376-1653
US

IV. Provider business mailing address

150 SAINT PETERS CENTRE BLVD STE B
SAINT PETERS MO
63376-1653
US

V. Phone/Fax

Practice location:
  • Phone: 636-466-8497
  • Fax: 636-244-1171
Mailing address:
  • Phone: 636-466-8497
  • Fax: 636-244-1171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2026019541
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: