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General NPI Number Information
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NPI Number | 1992504674
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Entity Type | Organization
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Legal Business Name | DYNAMITE COACH STL
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Dates
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Enumeration Date | 03/13/2025
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Last Update Date | 08/01/2025
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Provider Practice Location Address
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Address Line | 745 CRAIG RD STE 100
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City | CREVE COEUR
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State | MO
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Zip | 63141-7122
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Country | US
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Telephone | 314-443-1334
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Fax |
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Provider Business Mailing Address
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Address Line | 745 CRAIG RD STE 100
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City | CREVE COEUR
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State | MO
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Zip | 63141-7122
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Country | US
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Telephone | 314-443-1334
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TONYA WININGAR
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Credential | LPC
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Telephone | 314-443-1334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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