Provider Demographics
NPI:1730659376
Name:GREAT CIRCLE
Entity Type:Organization
Organization Name:GREAT CIRCLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:KLIETHERMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-303-7219
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559-0189
Mailing Address - Country:US
Mailing Address - Phone:573-265-3251
Mailing Address - Fax:573-265-5370
Practice Address - Street 1:330 N GORE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-1600
Practice Address - Country:US
Practice Address - Phone:314-968-2060
Practice Address - Fax:314-968-8308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-27
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty