Provider Demographics
NPI:1407906803
Name:AGAPE CHRISTIAN COUNSELING SERVICES
Entity Type:Organization
Organization Name:AGAPE CHRISTIAN COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVINSE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:314-994-9344
Mailing Address - Street 1:9378 OLIVE BLVD
Mailing Address - Street 2:STE. 317
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3215
Mailing Address - Country:US
Mailing Address - Phone:314-994-9344
Mailing Address - Fax:314-994-3007
Practice Address - Street 1:9378 OLIVE BLVD
Practice Address - Street 2:STE. 317
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3215
Practice Address - Country:US
Practice Address - Phone:314-994-9344
Practice Address - Fax:314-994-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004003789101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty