Provider Demographics
NPI:1346555729
Name:EDGEWOOD CHILDREN'S HOM'E
Entity Type:Organization
Organization Name:EDGEWOOD CHILDREN'S HOM'E
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:HERZBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MSA
Authorized Official - Phone:314-968-2060
Mailing Address - Street 1:330 N GORE
Mailing Address - Street 2:EDGEWOOD CHILDREN'S HOME
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 N GORE AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-1600
Practice Address - Country:US
Practice Address - Phone:314-968-2060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000266251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health