Provider Demographics
NPI:1962031385
Name:SHANTI SOURCE COUNSELING LLC
Entity Type:Organization
Organization Name:SHANTI SOURCE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-202-6867
Mailing Address - Street 1:2183 WIDE OAK CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7226
Mailing Address - Country:US
Mailing Address - Phone:314-541-1198
Mailing Address - Fax:
Practice Address - Street 1:11042 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-1244
Practice Address - Country:US
Practice Address - Phone:314-202-6867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty