MEDICARE: HOUSE OF PRAYER CHRISTIAN ACADEMY

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	101YP1600X	Pastoral Counselor
3	101YP2500X	Professional Counselor
4	106H00000X	Marriage & Family Therapist
5	101Y00000X	Counselor

General Provider Information

NPI Number	:	1700155595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSE OF PRAYER CHRISTIAN ACADEMY

Provider Business Mailing Address
First Line	:	5501 N PARK DR
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62204-2121
Country	:	US
Telephone Number	:	618-274-3850
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 N PARK DR
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62204-2121
Country	:	US
Telephone Number	:	618-274-3850
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. ANTHONY DEWAYNE PETTIFORD
Credential	:
Telephone Number	:	618-274-3850

Provider Enumeration Date	:	12/22/2011
Last Update Date	:	12/22/2011

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