Provider Demographics
NPI:1467802322
Name:LIBERATE LEARNING INSTITUTE
Entity Type:Organization
Organization Name:LIBERATE LEARNING INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JON-PIERRE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHOM
Authorized Official - Suffix:
Authorized Official - Credentials:PLPC
Authorized Official - Phone:314-690-9433
Mailing Address - Street 1:3833 MCREE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2619
Mailing Address - Country:US
Mailing Address - Phone:314-690-9433
Mailing Address - Fax:
Practice Address - Street 1:801 N 11TH ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1015
Practice Address - Country:US
Practice Address - Phone:314-690-9433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YM0800X, 101YP2500X, 1041C0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty