Provider Demographics
NPI:1942449194
Name:ANNIE MALONE CHILDREN AND FAMILY SERVICE CENTER
Entity type:Organization
Organization Name:ANNIE MALONE CHILDREN AND FAMILY SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL AND OUTPATIENT
Authorized Official - Prefix:
Authorized Official - First Name:CHANNEL
Authorized Official - Middle Name:GENISE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MED LPC TF-CBT NCC
Authorized Official - Phone:314-565-1110
Mailing Address - Street 1:2612 ANNIE MALONE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113
Mailing Address - Country:US
Mailing Address - Phone:314-531-0120
Mailing Address - Fax:314-531-0125
Practice Address - Street 1:5355 PAGE AVENUE
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112
Practice Address - Country:US
Practice Address - Phone:314-531-0120
Practice Address - Fax:314-531-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001305902385H00000X
MO002136058322D00000X
MOSEO200902251300000X
261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No385H00000XRespite Care FacilityRespite Care
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1942449194Medicaid
MO506278209Medicaid