Healthcare Provider Details

I. General information

NPI: 1063804821
Provider Name (Legal Business Name): BRYAN CHARLES DUCKHAM PHD, MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12125 WOODCREST EXEC. DRIVE STE 110
ST. LOUIS MO
63141
US

IV. Provider business mailing address

12125 WOODCREST EXEC. DRIVE STE 110
ST. LOUIS MO
63141
US

V. Phone/Fax

Practice location:
  • Phone: 314-275-8599
  • Fax: 314-275-8299
Mailing address:
  • Phone: 314-275-8599
  • Fax: 314-275-8299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number366
License Number StateMO

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: