Healthcare Provider Details

I. General information

NPI: 1801162474
Provider Name (Legal Business Name): MRS. MARSHA J IVESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARSHA J MILES CRADC

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 NORTH GRAND BLVD
ST. LOUIS MO
63107-1952
US

IV. Provider business mailing address

4218 N GRAND BLVD
SAINT LOUIS MO
63107-1806
US

V. Phone/Fax

Practice location:
  • Phone: 314-534-6624
  • Fax: 314-535-4394
Mailing address:
  • Phone: 313-534-6624
  • Fax: 314-535-4394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16090
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: