Basic Information
| Provider Information | |||||||||
| NPI: | 1588189377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEYER | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 OLIVE ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631032303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142063700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 760 PLANTATION BLVD | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710800 | ||||||||
| FaxNumber: | 5734710810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2017 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2017010561 | MO | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 2019025121 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2019025121 | 01 | MO | LICENSED CLINICAL SOCIAL WORKER | OTHER |