Provider Demographics
NPI:1720576663
Name:ST. LOUIS CENTER FOR COGNITIVE HEALTH, LLC
Entity Type:Organization
Organization Name:ST. LOUIS CENTER FOR COGNITIVE HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:ROBERTS REILLY
Authorized Official - Last Name:MENATTI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:314-833-4210
Mailing Address - Street 1:522 N NEW BALLAS RD STE 201
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6819
Mailing Address - Country:US
Mailing Address - Phone:314-833-4210
Mailing Address - Fax:314-833-4212
Practice Address - Street 1:522 N NEW BALLAS RD STE 201
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6819
Practice Address - Country:US
Practice Address - Phone:314-833-4210
Practice Address - Fax:314-833-4212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017002021103G00000X, 261QM0801X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty