Provider Demographics
NPI:1851459473
Name:FAMILY LIFE COUNSELING AND PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:FAMILY LIFE COUNSELING AND PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-300-9333
Mailing Address - Street 1:4142 KEATON CROSSING BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8404
Mailing Address - Country:US
Mailing Address - Phone:636-300-9333
Mailing Address - Fax:636-300-8761
Practice Address - Street 1:4142 KEATON CROSSING BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8404
Practice Address - Country:US
Practice Address - Phone:636-300-9333
Practice Address - Fax:636-300-8761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000166718103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO165530OtherBLUE CROSS BLUE SHIELD
MO000014023Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER