Healthcare Provider Details

I. General information

NPI: 1750587739
Provider Name (Legal Business Name): JUDSON R BLISS LPC, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CLARK AVE ST A
UNION MO
63084-1004
US

IV. Provider business mailing address

5 PREMIER DR STE 200
FENTON MO
63026-2943
US

V. Phone/Fax

Practice location:
  • Phone: 636-583-1800
  • Fax: 636-583-0836
Mailing address:
  • Phone: 314-544-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2007019560
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002010
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: