Provider Demographics
NPI:1154468601
Name:HENARES-LEVY, LOURDES (MD)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:HENARES-LEVY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 MCPHERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-4701
Mailing Address - Country:US
Mailing Address - Phone:314-725-4796
Mailing Address - Fax:314-725-0595
Practice Address - Street 1:6330 MCPHERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-4701
Practice Address - Country:US
Practice Address - Phone:314-725-4796
Practice Address - Fax:314-725-0595
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO358142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4502Medicare ID - Type Unspecified
MOG06599Medicare UPIN