Provider Demographics
NPI:1821744947
Name:CLOSSUM, RODNEY (MA)
Entity Type:Individual
Prefix:MR
First Name:RODNEY
Middle Name:
Last Name:CLOSSUM
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 CLEMENS COURT
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122
Mailing Address - Country:US
Mailing Address - Phone:314-971-4714
Mailing Address - Fax:
Practice Address - Street 1:1360 SOUTH FIFTH STREET SUITE 286
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301
Practice Address - Country:US
Practice Address - Phone:314-971-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005028055101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional