Provider Demographics
NPI:1073374989
Name:EPIR SOURCE MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:EPIR SOURCE MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:LATRECE
Authorized Official - Middle Name:MARLENE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-485-9241
Mailing Address - Street 1:819 AVONDALE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7835
Mailing Address - Country:US
Mailing Address - Phone:314-485-9241
Mailing Address - Fax:314-255-2501
Practice Address - Street 1:911 WASHINGTON AVE STE 501
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1272
Practice Address - Country:US
Practice Address - Phone:314-485-9241
Practice Address - Fax:314-255-2501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EPIR SOURCE MENTAL HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1003433202OtherNPI
1912594664OtherNPI
1629686381OtherNPI