Basic Information
| Provider Information | |||||||||
| NPI: | 1003428269 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CMG- NEW SEASON- ST. LOUIS METRO TREATMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9733 ST. CHARLES ROCK RD | ||||||||
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| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144237030 | ||||||||
| FaxNumber: | 3144239511 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 MAITLAND CENTER PARKWAY 250 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073517080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2020 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | PERKINS | ||||||||
| AuthorizedOfficialFirstName: | ANNE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 3144237030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CMG- NEW SEASON- ST. LOUIS METRO TREATMENT CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.