Healthcare Provider Details

I. General information

NPI: 1003062936
Provider Name (Legal Business Name): AGAPE COUNSELING SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4144 LINDELL BLVD SUITE 402
ST LOUIS MO
63108
US

IV. Provider business mailing address

1569 QUENDO AVENUE
ST LOUIS MO
63130-1419
US

V. Phone/Fax

Practice location:
  • Phone: 314-531-1601
  • Fax: 314-727-1921
Mailing address:
  • Phone: 314-727-7277
  • Fax: 314-727-1921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2000164578
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number20001164578
License Number StateMO

VIII. Authorized Official

Name: MR. ORENZA JOHN COTTON
Title or Position: PRESIDENT
Credential: LCSW
Phone: 314-531-1600