Provider Demographics
NPI:1467781393
Name:COVENANT HOUSE MISSOURI
Entity Type:Organization
Organization Name:COVENANT HOUSE MISSOURI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KERSTING
Authorized Official - Suffix:
Authorized Official - Credentials:MALPC
Authorized Official - Phone:314-450-7667
Mailing Address - Street 1:2727 N. KINGSHIGHWAY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113
Mailing Address - Country:US
Mailing Address - Phone:314-450-7667
Mailing Address - Fax:314-454-0005
Practice Address - Street 1:2727 N KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-1006
Practice Address - Country:US
Practice Address - Phone:314-450-7667
Practice Address - Fax:314-454-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-24
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004036418322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499019503Medicaid
MO1457324485OtherNPI