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General NPI Number Information
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NPI Number | 1326219866
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Entity Type | Organization
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Legal Business Name | THE BOYHOOD INITIATIVE OF MISSOURI
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Dates
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Enumeration Date | 03/12/2008
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Last Update Date | 04/28/2020
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Provider Practice Location Address
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Address Line | 8434 PAGE AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63130-1046
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Country | US
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Telephone | 314-882-6830
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Fax | 314-427-2303
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Provider Business Mailing Address
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Address Line | 8434 PAGE AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63130-1046
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Country | US
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Telephone | 314-882-6830
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Fax | 618-566-8186
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. HUEY LEE HAWKINS JR.
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Credential | LCSW
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Telephone | 314-882-6840
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 2002027247
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License Number State | MO
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