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General NPI Number Information
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NPI Number | 1073374989
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Entity Type | Organization
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Legal Business Name | EPIR SOURCE MENTAL HEALTH SERVICES
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Dates
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Enumeration Date | 01/18/2024
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Last Update Date | 01/18/2024
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Provider Practice Location Address
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Address Line | 911 WASHINGTON AVE STE 501
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City | SAINT LOUIS
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State | MO
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Zip | 63101-1272
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Country | US
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Telephone | 314-485-9241
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Fax | 314-255-2501
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Provider Business Mailing Address
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Address Line | 819 AVONDALE DR
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City | SAINT PETERS
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State | MO
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Zip | 63376-7835
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Country | US
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Telephone | 314-485-9241
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Fax | 314-255-2501
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | LATRECE MARLENE SMITH
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Credential | LCSW
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Telephone | 314-485-9241
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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