=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033572896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELAH THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2016
-----------------------------------------------------
Last Update Date | 03/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 CHURCH ST SUITE 103
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63135-2441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-522-8884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 CHURCH ST SUITE 103
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63135-2441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MRS. LA SHAUNA ANINGO
-----------------------------------------------------
Credential | MS.ED, LPC
-----------------------------------------------------
Telephone | 314-522-8884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------