Basic Information
| Provider Information | |||||||||
| NPI: | 1508857186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEYER | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | SEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LCPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | O'CONNELL | ||||||||
| OtherFirstName: | ELLEN | ||||||||
| OtherMiddleName: | SEAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 118 N 2ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362241210 | ||||||||
| FaxNumber: | 6369460991 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 COMMUNICATION DR | ||||||||
| Address2: | |||||||||
| City: | HANNIBAL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634013670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736031460 | ||||||||
| FaxNumber: | 5736031462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 05/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180-002139 | IL | N | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | SW 002874 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 494861610 | 05 | MO | MEDICAID |