Provider Demographics
NPI:1861026098
Name:SANA LAKE RECOVERY CENTER, LLC
Entity Type:Organization
Organization Name:SANA LAKE RECOVERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-392-3822
Mailing Address - Street 1:8350 STATE ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:DITTMER
Mailing Address - State:MO
Mailing Address - Zip Code:63023-1909
Mailing Address - Country:US
Mailing Address - Phone:636-944-4436
Mailing Address - Fax:
Practice Address - Street 1:140 WELDON PARKWAY
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043
Practice Address - Country:US
Practice Address - Phone:314-569-2278
Practice Address - Fax:314-569-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-26
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health