Basic Information
| Provider Information | |||||||||
| NPI: | 1427590371 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BJC BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 OLIVE ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631032303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142063800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1430 OLIVE ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631032303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142063800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2016 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | BERRONG | ||||||||
| AuthorizedOfficialFirstName: | BARBI | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3142063800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 267-7258 | MO | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 876175704 | 05 | MO | MEDICAID | 7107625 | 01 | MO | DEPT. OF MENTAL HEALTH | OTHER |