Provider Demographics
NPI:1073706248
Name:STOREY, BRIAN GLEN (DMIN)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GLEN
Last Name:STOREY
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 OAK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-4730
Mailing Address - Country:US
Mailing Address - Phone:314-580-7233
Mailing Address - Fax:314-835-1016
Practice Address - Street 1:7 JUNCTION DR
Practice Address - Street 2:STE. B
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-4300
Practice Address - Country:US
Practice Address - Phone:618-659-1606
Practice Address - Fax:314-835-1016
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3755101YP1600X
MO3755101YP1600X
MO300086106H00000X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist