MEDICARE: FAMILY WELLNESS COUNSELING, LC

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	1041C0700X	Clinical Social Worker	000112	MO

General Provider Information

NPI Number	:	1972799914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY WELLNESS COUNSELING, LC

Provider Business Mailing Address
First Line	:	1200 S LINDBERGH BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-2923
Country	:	US
Telephone Number	:	314-432-7927
Fax Number	:	314-991-1242

Provider Business Practice Location Address
First Line	:	1200 S LINDBERGH BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-2923
Country	:	US
Telephone Number	:	314-432-7927
Fax Number	:	314-991-1242

Authorized Official
Title or Position	:	PARTNER
Name	:	VIRGINIA A IVES
Credential	:	LCSW, MSW
Telephone Number	:	314-432-7927

Provider Enumeration Date	:	09/24/2007
Last Update Date	:	09/24/2007

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