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General NPI Number Information
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NPI Number | 1528640075
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Entity Type | Organization
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Legal Business Name | ST. LOUIS EATING RECOVERY THERAPY, LLC
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Dates
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Enumeration Date | 04/24/2021
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Last Update Date | 04/24/2021
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Provider Practice Location Address
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Address Line | 140 PROSPECT AVE STE L
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City | KIRKWOOD
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State | MO
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Zip | 63122-6024
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Country | US
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Telephone | 314-896-0810
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Fax |
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Provider Business Mailing Address
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Address Line | 637 S PAM AVE
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City | SAINT CHARLES
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State | MO
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Zip | 63301-4866
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | NICOLE JACOBS
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Credential | LPC, CEDS-S
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Telephone | 314-609-1874
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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 |
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License Number State |
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