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General NPI Number Information
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NPI Number | 1659047744
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Entity Type | Organization
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Legal Business Name | MAYDAI TRAUMA FOCUSED CLINICAL NETWORK AND RESEARCH CENTER LLC
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Dates
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Enumeration Date | 08/18/2021
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Last Update Date | 10/29/2021
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Provider Practice Location Address
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Address Line | 4601 STATE ST STE 220
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62205-1359
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Country | US
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Telephone | 618-741-9635
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Fax |
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Provider Business Mailing Address
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Address Line | 3144 VIRGINIA PL
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62207-1759
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Country | US
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Telephone | 618-741-9635
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Fax |
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | MR. KORY L MAY
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Credential | LCSW
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Telephone | 618-741-9635
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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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 |
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Taxonomy #3
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 163WP0200X
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Taxonomy Name | Pediatric Registered Nurse
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 405300000X
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Taxonomy Name | Prevention Professional
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License Number |
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License Number State |
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Taxonomy #10
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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 |
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