=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215259106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAPE CHRISTIAN COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2010
-----------------------------------------------------
Last Update Date | 02/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9378 OLIVE BLVD STE 317
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132-3224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-746-9622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9378 OLIVE BLVD STE 317
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132-3224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-746-9622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | L.P.C., N.C.C
-----------------------------------------------------
Name | DARRELL GEORGE PROVINSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-746-9622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 2009036114
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------