Provider Demographics
NPI:1730409053
Name:KIENTZLE, KATHERINE LONDON (MA PLPC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LONDON
Last Name:KIENTZLE
Suffix:
Gender:F
Credentials:MA PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 WINDSOR CT
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-3948
Mailing Address - Country:US
Mailing Address - Phone:314-491-7003
Mailing Address - Fax:
Practice Address - Street 1:11709 OLD BALLAS RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7029
Practice Address - Country:US
Practice Address - Phone:314-432-2428
Practice Address - Fax:314-432-2222
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009000557101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO27-1272761OtherTAX IDENTIFICATION NUMBER