Provider Demographics
NPI:1174921514
Name:NEUROTHERAPY CENTER OF ST LOUIS LLC
Entity type:Organization
Organization Name:NEUROTHERAPY CENTER OF ST LOUIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROTHERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:WIEGAND
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMFT, BCN
Authorized Official - Phone:309-369-8832
Mailing Address - Street 1:2834 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2627
Mailing Address - Country:US
Mailing Address - Phone:636-556-0873
Mailing Address - Fax:
Practice Address - Street 1:425 MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GRVS
Practice Address - State:MO
Practice Address - Zip Code:63119-1833
Practice Address - Country:US
Practice Address - Phone:636-556-0873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-17
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZE0600X, 246ZE0500X
MO2013031915106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEGGroup - Multi-Specialty
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty