Provider Demographics
NPI:1316005473
Name:PROVIDENT
Entity Type:Organization
Organization Name:PROVIDENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COUNSELING DIVISION
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BULIN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:314-371-6500
Mailing Address - Street 1:3675 W OUTER RD
Mailing Address - Street 2:203
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-5232
Mailing Address - Country:US
Mailing Address - Phone:314-898-0102
Mailing Address - Fax:636-296-3249
Practice Address - Street 1:3675 W OUTER RD
Practice Address - Street 2:203
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-5232
Practice Address - Country:US
Practice Address - Phone:314-898-0102
Practice Address - Fax:636-296-3249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002589251G00000X
MOSW002589305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251G00000XAgenciesHospice Care, Community Based
Not Answered305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO496768326Medicaid