Healthcare Provider Details

I. General information

NPI: 1649008475
Provider Name (Legal Business Name): PLAYHOUSE COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HUBER PARK CT STE 106
WELDON SPRING MO
63304-8683
US

IV. Provider business mailing address

500 HUBER PARK CT STE 106
WELDON SPRING MO
63304-8683
US

V. Phone/Fax

Practice location:
  • Phone: 636-344-0580
  • Fax:
Mailing address:
  • Phone: 636-344-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARIE BONNER-HORON
Title or Position: CO-FOUNDER
Credential: LPC, NCC, RPT-S, ACS
Phone: 618-292-5957