=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912665712
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARCIE BRADY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2021
-----------------------------------------------------
Last Update Date | 11/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2451 EXECUTIVE DR STE 205
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63303-5606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-858-6498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1036 GARDENBRIDGE PL
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63303-4820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-265-3857
-----------------------------------------------------
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 | 2022038456
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------