Provider Demographics
NPI:1528415536
Name:COMMUNITY & LONG-TERM CARE PSYCHIATRY LLC
Entity Type:Organization
Organization Name:COMMUNITY & LONG-TERM CARE PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:DICKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-849-0450
Mailing Address - Street 1:10004 KENNERLY RD
Mailing Address - Street 2:STE 362B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-849-0450
Mailing Address - Fax:314-849-0159
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:STE 362B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-849-0450
Practice Address - Fax:314-849-0159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015002634103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1265723407Medicaid
MO1265723407Medicaid