Provider Demographics
NPI:1306674890
Name:ISMAIL, MUDAR SOUFIAN (PLPC)
Entity type:Individual
Prefix:
First Name:MUDAR
Middle Name:SOUFIAN
Last Name:ISMAIL
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 TREESIDE CT APT I
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-0716
Mailing Address - Country:US
Mailing Address - Phone:636-856-7505
Mailing Address - Fax:
Practice Address - Street 1:4030 CHOUTEAU AVE STE 700
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1754
Practice Address - Country:US
Practice Address - Phone:314-680-9374
Practice Address - Fax:314-645-7802
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024010478101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional