Healthcare Provider Details

I. General information

NPI: 1942449194
Provider Name (Legal Business Name): ANNIE MALONE CHILDREN AND FAMILY SERVICE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5355 PAGE AVENUE
ST. LOUIS MO
63112
US

IV. Provider business mailing address

2612 ANNIE MALONE DRIVE
ST. LOUIS MO
63113
US

V. Phone/Fax

Practice location:
  • Phone: 314-531-0120
  • Fax: 314-531-0125
Mailing address:
  • Phone: 314-531-0120
  • Fax: 314-531-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License NumberSEO200902
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number002136058
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number001305902
License Number StateMO

VIII. Authorized Official

Name: CHANNEL GENISE THOMAS
Title or Position: DIRECTOR OF CLINICAL AND OUTPATIENT
Credential: M.ED. LPC TF-CBT NCC
Phone: 314-565-1110