=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891289617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH GAVIN BIVER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2018
-----------------------------------------------------
Last Update Date | 06/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 N GORE AVE
-----------------------------------------------------
City | WEBSTER GROVES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63119-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-968-2060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 623 E BRENTMOOR DR
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62294-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-971-7349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 178.013843
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------