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General NPI Number Information
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NPI Number | 1467802322
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Entity Type | Organization
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Legal Business Name | LIBERATE LEARNING INSTITUTE
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Dates
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Enumeration Date | 06/21/2016
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Last Update Date | 06/24/2016
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Provider Practice Location Address
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Address Line | 801 N 11TH ST
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City | SAINT LOUIS
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State | MO
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Zip | 63101-1015
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Country | US
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Telephone | 314-690-9433
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Fax |
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Provider Business Mailing Address
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Address Line | 3833 MCREE AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63110-2619
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Country | US
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Telephone | 314-690-9433
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Fax |
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Authorized Official
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Title or Position | FOUNDER/CEO
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Name | MR. JON-PIERRE MITCHOM
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Credential | PLPC
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Telephone | 314-690-9433
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State | MO
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Taxonomy #2
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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 | MO
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State | MO
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | MO
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