Provider Demographics
NPI:1740632827
Name:TEA TREE BEHAVIORAL HEALTH & THERAPY LLC
Entity type:Organization
Organization Name:TEA TREE BEHAVIORAL HEALTH & THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GILMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:636-484-4371
Mailing Address - Street 1:5323 MIRASOL MANOR WAY
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-2751
Mailing Address - Country:US
Mailing Address - Phone:636-484-4371
Mailing Address - Fax:
Practice Address - Street 1:102 S MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084-1814
Practice Address - Country:US
Practice Address - Phone:636-484-4371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013041575101YP2500X
MO2013008645101YP2500X
MO20110284601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty