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NPI Code Detail

MEDICARE: LEO GORMLEY CRADC

MEDICARE: LEO GORMLEY CRADC
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
1101YA0400XAddiction (Substance Use Disorder) Counselor
2101YA0400XAddiction (Substance Use Disorder) Counselor11787MO

General Provider Information

NPI Number : 1811392798
Entity Type Code : Individual
Provider Name (Legal Business Name) : LEO GORMLEY CRADC
Provider Business Mailing Address
First Line : 1430 OLIVE ST STE 400
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63103-2303
Country : US
Telephone Number : 314-206-3700
Fax Number :
Provider Business Practice Location Address
First Line : 6763 PAGE AVE # MO
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63133-1635
Country : US
Telephone Number : 314-206-3910
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/04/2014
Last Update Date : 03/22/2022

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Directions to “ LEO GORMLEY CRADC” Practice Location

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