Provider Demographics
NPI:1538269477
Name:LEDESMA, TAWNA MARIE (MED, LPC)
Entity type:Individual
Prefix:
First Name:TAWNA
Middle Name:MARIE
Last Name:LEDESMA
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 OAKLAND AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1871
Mailing Address - Country:US
Mailing Address - Phone:314-629-4117
Mailing Address - Fax:
Practice Address - Street 1:7110 OAKLAND AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1871
Practice Address - Country:US
Practice Address - Phone:314-629-4117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018980101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494884323Medicare ID - Type Unspecified