Healthcare Provider Details

I. General information

NPI: 1285099143
Provider Name (Legal Business Name): PIVOT COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2015
Last Update Date: 12/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7526 BIG BEND BLVD
WEBSTER GROVES MO
63119-2104
US

IV. Provider business mailing address

7526 BIG BEND BLVD
WEBSTER GROVES MO
63119-2104
US

V. Phone/Fax

Practice location:
  • Phone: 314-578-7608
  • Fax:
Mailing address:
  • Phone: 314-578-7608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2014016172
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier1952574212
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: JENNIE OBERKROM
Title or Position: OWNER
Credential: LCSW
Phone: 314-578-7608