=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811435845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALK COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2017
-----------------------------------------------------
Last Update Date | 02/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 HACIENDA DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63124-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-276-5354
-----------------------------------------------------
Fax | 314-993-5354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 HACIENDA DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63124-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-276-5354
-----------------------------------------------------
Fax | 314-993-5354
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | ANN L KANTOR
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 314-276-5354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 001181
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------