Organization · Type 2 NPI

State of Missouri

Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility · St. Louis, MO

NPI number 1942442702 Active

Practice location

11 Brady Cir
St. Louis, MO 63114-1110

Call (314) 877-1624 Map

Fax (314) 877-5666

Mailing address

1706 E Elm St
Jefferson City, MO 65101-4130

Specialties and licenses

Taxonomy	Code	License
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility Primary	320900000X	None listed

Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility: A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with intellectual and/or developmental disabilities.

2 other providers at this address

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NPI record

NPI: 1942442702
Entity type: Organization (Type 2)
Issued: Mar 25, 2009
Last updated: Aug 28, 2020
Status: Active
Subpart: Yes of State of Missouri

Other names

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St. Louis Developmental Disabilities Treatment Center Isl · doing business as
St. Louis Developmental Disabilities Treatment Center Isl · doing business as

Authorized official

Molly Jane Boeckmann
Director of Administrative Services
(573) 751-4055

Verify this record

This page mirrors the public NPPES file. For credentialing or billing, confirm it on the official CMS NPI Registry, and check the license with the state board.

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About NPI 1942442702

State of Missouri's National Provider Identifier is 1942442702, issued on Mar 25, 2009. The primary taxonomy on file is Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility (320900000X), and the practice location is in St. Louis, MO. The record was last updated on Aug 28, 2020.