Provider Demographics
NPI:1700155595
Name:HOUSE OF PRAYER CHRISTIAN ACADEMY
Entity type:Organization
Organization Name:HOUSE OF PRAYER CHRISTIAN ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:PETTIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-274-3850
Mailing Address - Street 1:5501 N PARK DR
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62204-2121
Mailing Address - Country:US
Mailing Address - Phone:618-274-3850
Mailing Address - Fax:
Practice Address - Street 1:5501 N PARK DR
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62204-2121
Practice Address - Country:US
Practice Address - Phone:618-274-3850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty