Provider Demographics
NPI:1720552920
Name:MARESCHAL, GLENDA MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:MARIE
Last Name:MARESCHAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:GLENDA
Other - Middle Name:MARIE
Other - Last Name:MERCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3421
Mailing Address - Country:US
Mailing Address - Phone:636-688-9907
Mailing Address - Fax:
Practice Address - Street 1:500 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3421
Practice Address - Country:US
Practice Address - Phone:636-688-9907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110278641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431343281Medicaid