Provider Demographics
NPI:1801280839
Name:JULIE WITHWORTH
Entity type:Organization
Organization Name:JULIE WITHWORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RENITA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-436-9300
Mailing Address - Street 1:916 OLIVE ST # 312
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63101-1459
Mailing Address - Country:US
Mailing Address - Phone:314-436-9300
Mailing Address - Fax:314-802-4477
Practice Address - Street 1:916 OLIVE ST # 312
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1459
Practice Address - Country:US
Practice Address - Phone:314-436-9300
Practice Address - Fax:314-802-4477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014036356363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1619372240Medicaid