Healthcare Provider Details

I. General information

NPI: 1497065585
Provider Name (Legal Business Name): PETINA COLLIER LINDSEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2536 OLD HIGHWAY 94 S. SUITE #220
ST.. CHARLES MO
63303-5612
US

IV. Provider business mailing address

2536 OLD HIGHWAY 94 S. SUITE #220
ST.. CHARLES MO
63303-5612
US

V. Phone/Fax

Practice location:
  • Phone: 636-922-2000
  • Fax: 636-329-0994
Mailing address:
  • Phone: 636-922-2000
  • Fax: 636-329-0994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005699
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier494653421
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 2
IdentifierMA2556
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerMEDICARE

VIII. Authorized Official

Name: PETINA COLLIER LINDSEY
Title or Position: THERAPIST
Credential: MSW
Phone: 314-322-3326