MEDICARE: MR. MOYENDA ANWISYE THOMPSON

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	101YP2500X	Professional Counselor	2011040308	MO

General Provider Information

NPI Number	:	1962823666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MOYENDA ANWISYE THOMPSON

Provider Business Mailing Address
First Line	:	PO BOX 29033
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63112-0733
Country	:	US
Telephone Number	:	314-749-5954
Fax Number	:

Provider Business Practice Location Address
First Line	:	1422 GRANVILLE PL
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63112-4202
Country	:	US
Telephone Number	:	314-749-5954
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2013
Last Update Date	:	12/23/2013

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