Provider Demographics
NPI:1790814309
Name:FLORISSANT PSYCHOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:FLORISSANT PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:FREDRICK
Authorized Official - Last Name:DETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-837-7828
Mailing Address - Street 1:701 ST. FRANCOIS
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-4921
Mailing Address - Country:US
Mailing Address - Phone:314-837-7828
Mailing Address - Fax:
Practice Address - Street 1:701 SAINT FRANCOIS ST
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-4921
Practice Address - Country:US
Practice Address - Phone:314-837-7828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000043101Y00000X
MO001427101Y00000X
MO00843103T00000X
MO2006029901103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty