1700484599 NPI number — INSTITUTE OF INTRAPERSONAL DEVELOPMENT, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700484599 NPI number — INSTITUTE OF INTRAPERSONAL DEVELOPMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INSTITUTE OF INTRAPERSONAL DEVELOPMENT, LLC
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:
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:
1700484599
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1872 WOODHOLLOW DRIVE
Provider Second Line Business Mailing Address:
APT. 211
Provider Business Mailing Address City Name:
MARYLAND HEIGHTS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63043-3957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-625-6070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1872 WOODHOLLOW DRIVE
Provider Second Line Business Practice Location Address:
APT. 211
Provider Business Practice Location Address City Name:
MARYLAND HEIGHTS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63043-3957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-625-6070
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2020

Additional Information

Authorized Official

Authorized Official Last Name:
RUTLIN
Authorized Official First Name:
JERISHA
Authorized Official Middle Name:
LACRAE
Authorized Official Title or Position:
FOUNDER/CLINICAL DIRECTOR
Authorized Official Telephone Number:
314-625-6070

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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