Provider Demographics
NPI:1174668289
Name:INDEPENDENCE CENTER
Entity Type:Organization
Organization Name:INDEPENDENCE CENTER
Other - Org Name:INDEPENDENCE CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-880-5415
Mailing Address - Street 1:4245 FOREST PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2810
Mailing Address - Country:US
Mailing Address - Phone:314-880-5401
Mailing Address - Fax:314-880-5468
Practice Address - Street 1:4219 LACLEDE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2814
Practice Address - Country:US
Practice Address - Phone:314-286-4545
Practice Address - Fax:314-286-4542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO503350506Medicaid
MO560003943Medicaid
000013046Medicare PIN