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General NPI Number Information
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NPI Number | 1467781393
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Entity Type | Organization
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Legal Business Name | COVENANT HOUSE MISSOURI
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Dates
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Enumeration Date | 12/24/2009
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Last Update Date | 12/24/2009
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Provider Practice Location Address
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Address Line | 2727 N KINGSHIGHWAY BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63113-1006
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Country | US
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Telephone | 314-450-7667
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Fax | 314-454-0005
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Provider Business Mailing Address
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Address Line | 2727 N. KINGSHIGHWAY BOULEVARD
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City | ST. LOUIS
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State | MO
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Zip | 63113
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Country | US
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Telephone | 314-450-7667
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Fax | 314-454-0005
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Authorized Official
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Title or Position | CLINICAL COORDINATOR
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Name | MS. KRISTINA R KERSTING
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Credential | MALPC
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Telephone | 314-450-7667
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 2004036418
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License Number State | MO
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