Provider Demographics
NPI:1700911369
Name:FAMILY SUPPORT NETWORK
Entity Type:Organization
Organization Name:FAMILY SUPPORT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MA LPC
Authorized Official - Phone:314-644-5055
Mailing Address - Street 1:570 SHACKELFORD RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-5457
Mailing Address - Country:US
Mailing Address - Phone:314-830-1796
Mailing Address - Fax:
Practice Address - Street 1:7514 BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2104
Practice Address - Country:US
Practice Address - Phone:314-644-5055
Practice Address - Fax:314-644-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002006418251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management