=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508200767
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY L DENEAL LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2013
-----------------------------------------------------
Last Update Date | 02/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8050 WATSON RD SUITE 335
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63119-5329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-447-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 264 MAPLE DR
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63026-3224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2006017537
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------