Healthcare Provider Details

I. General information

NPI: 1740714823
Provider Name (Legal Business Name): STORGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7114 VERNON AVE
UNIVERSITY CITY MO
63130-2301
US

IV. Provider business mailing address

PO BOX 142860
SAINT LOUIS MO
63114-0860
US

V. Phone/Fax

Practice location:
  • Phone: 314-475-4147
  • Fax: 314-216-3710
Mailing address:
  • Phone: 314-475-4147
  • Fax: 314-282-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEJA RENEE SCOTT
Title or Position: CEO
Credential:
Phone: 314-449-9420