Provider Demographics
NPI:1720575350
Name:PLAYFULLEIGH PSYCHED, LLC
Entity Type:Organization
Organization Name:PLAYFULLEIGH PSYCHED, LLC
Other - Org Name:PLAYFULLEIGH PSYCHED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LATRICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOWTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCPC, NCSP
Authorized Official - Phone:202-499-9188
Mailing Address - Street 1:2920 MERAMEC ST UNIT 26909
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-4462
Mailing Address - Country:US
Mailing Address - Phone:202-838-7529
Mailing Address - Fax:
Practice Address - Street 1:2920 MERAMEC ST UNIT 26909
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-4462
Practice Address - Country:US
Practice Address - Phone:202-838-7529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 103TC0700X
MDLC8553261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty