Provider Demographics
NPI:1952463630
Name:WREN, NICHOLAS ANTON (LPC)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ANTON
Last Name:WREN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9137 OLD BONHOMME RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-4417
Mailing Address - Country:US
Mailing Address - Phone:314-489-9517
Mailing Address - Fax:314-584-2079
Practice Address - Street 1:9137 OLD BONHOMME RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-4417
Practice Address - Country:US
Practice Address - Phone:314-489-9517
Practice Address - Fax:314-584-2079
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001033822101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490814605Medicaid