Provider Demographics
NPI:1639736515
Name:CHILD AND ADOLESCENT LIFE THERAPY
Entity Type:Organization
Organization Name:CHILD AND ADOLESCENT LIFE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:314-440-8468
Mailing Address - Street 1:4390 LINDELL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2735
Mailing Address - Country:US
Mailing Address - Phone:314-744-9002
Mailing Address - Fax:
Practice Address - Street 1:4390 LINDELL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2735
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-25
Last Update Date:2019-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty