Provider Demographics
NPI:1215076898
Name:ST. LOUIS ARC INC
Entity type:Organization
Organization Name:ST. LOUIS ARC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TISONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-569-2211
Mailing Address - Street 1:1177 N. WARSON RD.
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132
Mailing Address - Country:US
Mailing Address - Phone:314-569-2211
Mailing Address - Fax:314-569-3656
Practice Address - Street 1:1177 N. WARSON RD.
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132
Practice Address - Country:US
Practice Address - Phone:314-569-2211
Practice Address - Fax:314-569-3656
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. LOUIS ARC INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-06
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5073876032251P0200X, 225XP0200X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507387603Medicaid