Basic Information
Provider Information | |||||||||
NPI: | 1508310632 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREFERRED FAMILY HEALTHCARE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BRIDGEWAY BEHAVIORAL HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1601 OLD SOUTH RIVER RD | ||||||||
Address2: |   | ||||||||
City: | SAINT CHARLES | ||||||||
State: | MO | ||||||||
PostalCode: | 633034120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362241210 | ||||||||
FaxNumber: | 6362461008 | ||||||||
Practice Location | |||||||||
Address1: | 2120 PARKWAY DR | ||||||||
Address2: |   | ||||||||
City: | SAINT PETERS | ||||||||
State: | MO | ||||||||
PostalCode: | 63376 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362241200 | ||||||||
FaxNumber: | 6369251443 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2016 | ||||||||
LastUpdateDate: | 07/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONOVER | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF REVENUE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6606651962 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 324500000X |   |   | N |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   | 101YA0400X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.