=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780369405
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA FLORA WISS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2023
-----------------------------------------------------
Last Update Date | 06/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 FERN RIDGE PKWY STE 110
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-4405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-275-8599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6925 COLUMBIA AVE
-----------------------------------------------------
City | UNIVERSITY CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63130-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-324-3581
-----------------------------------------------------
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 | 2022028185
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------