=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750089421
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES DUANE VALENTI-HEIN PHD, BCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2023
-----------------------------------------------------
Last Update Date | 02/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 EDMUNDSON RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63134-3806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-831-8550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4600 EDMUNDSON RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63134-3806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-831-8550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374K00000X
-----------------------------------------------------
Taxonomy Name | Religious Nonmedical Practitioner
-----------------------------------------------------
License Number | 65114
-----------------------------------------------------
License Number State |
-----------------------------------------------------