{
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"FirstLineMailingAddress": "PO BOX 50053",
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"MailingAddressCityName": "ALBUQUERQUE",
"MailingAddressStateName": "NM",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "314-800-0311",
"MailingAddressFaxNumber": "314-228-0367",
"FirstLinePracticeLocationAddress": "8045 BIG BEND BLVD STE 101/109",
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"PracticeLocationAddressCityName": "SAINT LOUIS",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "314-800-0311",
"PracticeLocationAddressFaxNumber": "314-228-0367",
"EnumerationDate": "05/16/2017",
"LastUpdateDate": "11/08/2021",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "DEAS",
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"AuthorizedOfficialCredential": "LCSW",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QM0801X",
"TaxonomyName": "Mental Health Clinic/Center (Including Community Mental Health Center)",
"LicenseNumber": "2011350180",
"LicenseNumberStateCode": "MO",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}