MEDICARE: AVENUES COUNSELING CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	2003031565	MO

General Provider Information

NPI Number	:	1104226323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVENUES COUNSELING CENTER

Provider Business Mailing Address
First Line	:	1612 S BIG BEND BLVD
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	MO
Zip	:	63117-2208
Country	:	US
Telephone Number	:	314-529-1391
Fax Number	:

Provider Business Practice Location Address
First Line	:	1612 S BIG BEND BLVD
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	MO
Zip	:	63117-2208
Country	:	US
Telephone Number	:	314-529-1391
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. LIANNE GIORDANO JOHNSON
Credential	:	LPC
Telephone Number	:	314-443-4069

Provider Enumeration Date	:	08/25/2014
Last Update Date	:	08/25/2014

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