Healthcare Provider Details

I. General information

NPI: 1760001457
Provider Name (Legal Business Name): KIMBERLEY MCGUINESS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 11/27/2023
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 LAMP AND LANTERN VILLAGE
TOWN AND COUNTRY MO
36017
US

IV. Provider business mailing address

13037 WHEATFIELD FARM RD
SAINT LOUIS MO
63141-8546
US

V. Phone/Fax

Practice location:
  • Phone: 314-283-7617
  • Fax:
Mailing address:
  • Phone: 314-283-7617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2019003417
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2019003417
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: