1003062936 NPI number — AGAPE COUNSELING SERVICE INC

Table of content: (NPI 1003062936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003062936 NPI number — AGAPE COUNSELING SERVICE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGAPE COUNSELING SERVICE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003062936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1569 QUENDO AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63130-1419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-727-7277
Provider Business Mailing Address Fax Number:
314-727-1921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4144 LINDELL BLVD
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-531-1601
Provider Business Practice Location Address Fax Number:
314-727-1921
Provider Enumeration Date:
08/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
COTTON
Authorized Official First Name:
ORENZA
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-531-1600

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  20001164578 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 2000164578 , 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)

  • Identifier: 2000165478 . This is a "LCSW MARRIAGE & FAMILY THERAPY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 495945404 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 856261409 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 856261409 . This is a "MEDICAID WAIVER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: CASAC 2513 . This is a "ADDICTION DIAGNOSIS & TREARMENT" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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