Basic Information
| Provider Information | |||||||||
| NPI: | 1043881949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERKEN | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PL-MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 OLD SOUTH RIVER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633034120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362241210 | ||||||||
| FaxNumber: | 6369461008 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 WESTBURY DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369466476 | ||||||||
| FaxNumber: | 6369466479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2021 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 2020009142 | MO | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.