Provider Demographics
NPI:1417282146
Name:IMANI COUNSELING AND CONSULTING SERVICES
Entity Type:Organization
Organization Name:IMANI COUNSELING AND CONSULTING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY-MCGHEE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:314-344-0983
Mailing Address - Street 1:14220 OLD HALLS FERRY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14220 OLD HALLS FERRY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-2400
Practice Address - Country:US
Practice Address - Phone:314-344-0983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003015970101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498356617Medicaid