Basic Information
| Provider Information | |||||||||
| NPI: | 1801807847 | ||||||||
| 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: | 3142063700 | ||||||||
| FaxNumber: | 3142063881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1085 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636401955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737565353 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | ROTHERY | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3142730791 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 267-7258 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 7107617 | 01 | MO DEPT OF MENTAL HEALTH | OTHER | 154902019 | 05 | MO | MEDICAID | 876175811 | 05 | MO | MEDICAID | 876175803 | 05 | MO | MEDICAID | 154902001 | 05 | MO | MEDICAID |