Provider Demographics
NPI:1396866646
Name:MU'MIN, ROESHELLE RENNE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ROESHELLE
Middle Name:RENNE
Last Name:MU'MIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11222 BELLEFONTAINE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138-1037
Mailing Address - Country:US
Mailing Address - Phone:314-691-7815
Mailing Address - Fax:314-438-9398
Practice Address - Street 1:11222 BELLEFONTAINE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-1037
Practice Address - Country:US
Practice Address - Phone:314-691-7815
Practice Address - Fax:314-438-9398
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040192271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical