=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568100915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VALLE ANNE DIEBOLD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2022
-----------------------------------------------------
Last Update Date | 05/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4625 LINDELL BLVD STE 200
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63108-3725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-387-9589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 AUBURN TRACE LN
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-304-3536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2007012544
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------