Provider Demographics
NPI:1417750050
Name:ZELLE, RICHARD LEROY III
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LEROY
Last Name:ZELLE
Suffix:III
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 AUBER DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4302
Mailing Address - Country:US
Mailing Address - Phone:314-339-6622
Mailing Address - Fax:
Practice Address - Street 1:1196 W SOUTH JORDAN PKWY STE D2
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4604
Practice Address - Country:US
Practice Address - Phone:385-533-9590
Practice Address - Fax:385-446-0039
Is Sole Proprietor?:No
Enumeration Date:2025-03-29
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO19108101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)