Provider Demographics
NPI:1003062936
Name:AGAPE COUNSELING SERVICE INC
Entity Type:Organization
Organization Name:AGAPE COUNSELING SERVICE INC
Other - Org Name:AGAPE COUNSELING SERVICE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ORENZA
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:COTTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-531-1600
Mailing Address - Street 1:1569 QUENDO AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-1419
Mailing Address - Country:US
Mailing Address - Phone:314-727-7277
Mailing Address - Fax:314-727-1921
Practice Address - Street 1:4144 LINDELL BLVD
Practice Address - Street 2:SUITE 402
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108
Practice Address - Country:US
Practice Address - Phone:314-531-1601
Practice Address - Fax:314-727-1921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001645781041C0700X
MO20001164578320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2000165478OtherLCSW MARRIAGE & FAMILY THERAPY
MO495945404Medicaid
MO856261409Medicaid
MO856261409OtherMEDICAID WAIVER
MOCASAC 2513OtherADDICTION DIAGNOSIS & TREARMENT
MO856261409Medicaid