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General NPI Number Information
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NPI Number | 1528415536
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Entity Type | Organization
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Legal Business Name | COMMUNITY & LONG-TERM CARE PSYCHIATRY LLC
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Dates
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Enumeration Date | 05/19/2016
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Last Update Date | 05/19/2016
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Provider Practice Location Address
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Address Line | 10004 KENNERLY RD STE 362B
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City | SAINT LOUIS
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State | MO
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Zip | 63128-2141
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Country | US
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Telephone | 314-849-0450
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Fax | 314-849-0159
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Provider Business Mailing Address
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Address Line | 10004 KENNERLY RD STE 362B
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City | SAINT LOUIS
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State | MO
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Zip | 63128-2141
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Country | US
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Telephone | 314-849-0450
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Fax | 314-849-0159
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | MRS. BETTY JANE DICKERMAN
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Credential |
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Telephone | 314-849-0450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 2015002634
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License Number State | MO
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