Provider Demographics
NPI:1215259106
Name:AGAPE CHRISTIAN COUNSELING SERVICES
Entity type:Organization
Organization Name:AGAPE CHRISTIAN COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:L.P.C., N.C.C
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:PROVINSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-746-9622
Mailing Address - Street 1:9378 OLIVE BLVD STE 317
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3224
Mailing Address - Country:US
Mailing Address - Phone:314-746-9622
Mailing Address - Fax:
Practice Address - Street 1:9378 OLIVE BLVD STE 317
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3224
Practice Address - Country:US
Practice Address - Phone:314-746-9622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009036114251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health