Healthcare Provider Details

I. General information

NPI: 1215768486
Provider Name (Legal Business Name): LIFE IN BALANCE STL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8780 BIG BEND BLVD STE B
WEBSTER GROVES MO
63119-3774
US

IV. Provider business mailing address

320 W GLENDALE RD
SAINT LOUIS MO
63119-4057
US

V. Phone/Fax

Practice location:
  • Phone: 314-472-8180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA SAMUELS
Title or Position: OWNER
Credential:
Phone: 314-482-3450