Provider Demographics
NPI:1780051862
Name:THE COLLABORATIVE. COUNSELING - CONSULTATION - RESOURCES LLC
Entity type:Organization
Organization Name:THE COLLABORATIVE. COUNSELING - CONSULTATION - RESOURCES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC, NCC, RPT
Authorized Official - Phone:636-477-6500
Mailing Address - Street 1:293 TYNDALE DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-7553
Mailing Address - Country:US
Mailing Address - Phone:636-544-6039
Mailing Address - Fax:
Practice Address - Street 1:1480 WOODSTONE DR STE 112
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-6872
Practice Address - Country:US
Practice Address - Phone:636-477-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010016700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty