MEDICARE: EATING DISORDER RECOVERY 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	251S00000X	Community/Behavioral Health Agency	6196-9774	MO

General Provider Information

NPI Number	:	1831377464
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EATING DISORDER RECOVERY CENTER

Provider Business Mailing Address
First Line	:	1034 S BRENTWOOD BLVD
Second Line	:	SUITE 694
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1223
Country	:	US
Telephone Number	:	314-721-5514
Fax Number	:

Provider Business Practice Location Address
First Line	:	1034 S BRENTWOOD BLVD
Second Line	:	SUITE 694
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1223
Country	:	US
Telephone Number	:	314-721-5514
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. DEBORAH JOY KUEHNEL
Credential	:	LCSW
Telephone Number	:	314-721-5514

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	02/06/2008

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