Basic Information
| Provider Information | |||||||||
| NPI: | 1679604318 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMANDA LUCKETT MURPHY HOPEWELL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 DELMAR BLVD. | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631122617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143677848 | ||||||||
| FaxNumber: | 3143675637 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 NORTH 14TH STREET | ||||||||
| Address2: | |||||||||
| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145311770 | ||||||||
| FaxNumber: | 3142411185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | TILLETT | ||||||||
| AuthorizedOfficialFirstName: | HEWART | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3143677848 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 560578007 | 05 | MO | MEDICAID |