Provider Demographics
NPI:1659817427
Name:DETTLEFF, RACHEL (LMSW, CRADC)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:DETTLEFF
Suffix:
Gender:F
Credentials:LMSW, CRADC
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:
Other - Last Name:DETTLEFF-SCHMIDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW, CRADC
Mailing Address - Street 1:4130 LINDELL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2914
Mailing Address - Country:US
Mailing Address - Phone:314-535-5600
Mailing Address - Fax:314-535-6037
Practice Address - Street 1:4130 LINDELL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2914
Practice Address - Country:US
Practice Address - Phone:314-535-5600
Practice Address - Fax:314-535-6037
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO8878101YA0400X
MO2013000349104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker