Basic Information
| Provider Information | |||||||||
| NPI: | 1639494891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEBSTER WELLNESS PROFESSIONALS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 231 W LOCKWOOD AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631192951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147374070 | ||||||||
| FaxNumber: | 3147374071 | ||||||||
| Practice Location | |||||||||
| Address1: | 231 W LOCKWOOD AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631192951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147374070 | ||||||||
| FaxNumber: | 3147374071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2010 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | FLANERY | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3147374070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCCALLUM GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | RO282 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.