Healthcare Provider Details

I. General information

NPI: 1346555729
Provider Name (Legal Business Name): EDGEWOOD CHILDREN'S HOM'E
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N GORE AVE
WEBSTER GROVES MO
63119-1600
US

IV. Provider business mailing address

330 N GORE EDGEWOOD CHILDREN'S HOME
WEBSTER GROVES MO
63119
US

V. Phone/Fax

Practice location:
  • Phone: 314-968-2060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number000266
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number000266
License Number StateMO

VIII. Authorized Official

Name: MS. JOANNE P HERZBERG
Title or Position: THERAPIST
Credential: MSA
Phone: 314-968-2060