1639604630 NPI number — REBECCA DOUGHERTY FROELKE MSW, LCSW

Table of content: REBECCA DOUGHERTY FROELKE MSW, LCSW (NPI 1639604630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639604630 NPI number — REBECCA DOUGHERTY FROELKE MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGHERTY FROELKE
Provider First Name:
REBECCA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOUGHERTY
Provider Other First Name:
REBECCA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1639604630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5640 TELEGRAPH RD # 303B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63129-4243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-800-7608
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5640 TELEGRAPH RD # 303B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63129-4243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-800-7608
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  2000164412 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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