Provider Demographics
NPI:1679685119
Name:HART, DAVID LOREN JR (PH D, LPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LOREN
Last Name:HART
Suffix:JR
Gender:M
Credentials:PH D, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-1414
Mailing Address - Country:US
Mailing Address - Phone:314-664-6151
Mailing Address - Fax:314-351-2940
Practice Address - Street 1:4561 S COMPTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-1554
Practice Address - Country:US
Practice Address - Phone:314-352-1770
Practice Address - Fax:314-351-2940
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCS002663101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493917603Medicaid