Healthcare Provider Details

I. General information

NPI: 1376770438
Provider Name (Legal Business Name): FRED P BARKER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 W MAIN ST STE 311
WENTZVILLE MO
63385-1600
US

IV. Provider business mailing address

31 COYOTE RIDGE LN
DEFIANCE MO
63341-1360
US

V. Phone/Fax

Practice location:
  • Phone: 636-486-6359
  • Fax:
Mailing address:
  • Phone: 636-485-0470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2005041410
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: