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General NPI Number Information
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NPI Number | 1780051862
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Entity Type | Organization
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Legal Business Name | THE COLLABORATIVE. COUNSELING - CONSULTATION - RESOURCES LLC
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Dates
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Enumeration Date | 08/25/2015
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Last Update Date | 08/25/2015
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Provider Practice Location Address
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Address Line | 1480 WOODSTONE DR STE 112
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City | SAINT CHARLES
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State | MO
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Zip | 63304-6872
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Country | US
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Telephone | 636-477-6500
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Fax |
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Provider Business Mailing Address
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Address Line | 293 TYNDALE DR
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City | O FALLON
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State | MO
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Zip | 63366-7553
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Country | US
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Telephone | 636-544-6039
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | BRENDA LORRAINE BRYANT
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Credential | M.ED, LPC, NCC, RPT
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Telephone | 636-477-6500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 2010016700
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License Number State | MO
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