=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992328710
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERYL KINNEY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2020
-----------------------------------------------------
Last Update Date | 09/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 623 MERAMEC STATION RD
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63021-5550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-266-9131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1237 WARSON WOODS DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-608-2527
-----------------------------------------------------
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 | 005288
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------