Healthcare Provider Details

I. General information

NPI: 1487880050
Provider Name (Legal Business Name): M SUSAN DAWSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY SUSAN DAWSON PMHNP

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 OLIVE STREET
ST. LOUIS MO
63103
US

IV. Provider business mailing address

2650 OLIVE STREET
ST. LOUIS MO
63103
US

V. Phone/Fax

Practice location:
  • Phone: 314-371-6500
  • Fax: 314-371-6508
Mailing address:
  • Phone: 314-371-6500
  • Fax: 314-371-6508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number065344
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberT114819
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number209.005621
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number065344
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: