1750587739 NPI number — DR. JUDSON R BLISS LPC, LCSW

Table of content: DR. JUDSON R BLISS LPC, LCSW (NPI 1750587739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750587739 NPI number — DR. JUDSON R BLISS LPC, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLISS
Provider First Name:
JUDSON
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LPC, LCSW
Provider Gender Code:
M

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:
1750587739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 PREMIER DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63026-2943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-544-3800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 CLARK AVE
Provider Second Line Business Practice Location Address:
ST A
Provider Business Practice Location Address City Name:
UNION
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63084-1004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-583-1800
Provider Business Practice Location Address Fax Number:
636-583-0836
Provider Enumeration Date:
06/26/2007

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:  2007019560 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 002010 , 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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