Provider Demographics
NPI:1578192308
Name:MEMOIR COUNSELING, LLC
Entity Type:Organization
Organization Name:MEMOIR COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARGAUX
Authorized Official - Middle Name:
Authorized Official - Last Name:KERVIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CADC
Authorized Official - Phone:816-866-0334
Mailing Address - Street 1:2906 NE RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64117-2167
Mailing Address - Country:US
Mailing Address - Phone:913-645-5733
Mailing Address - Fax:
Practice Address - Street 1:4731 S COCHISE DR STE 206
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6975
Practice Address - Country:US
Practice Address - Phone:816-373-6433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1194244541Medicaid