26D2177026 CLIA NUMBER - PROVIDENT INC (DBA PROVIDENT BEHAVORIAL HEALTH)

Laboratory Demographics

  • CLIA Code: 26D2177026
  • Facility Name: PROVIDENT INC (DBA PROVIDENT BEHAVORIAL HEALTH)
  • Facility Address: 2650 OLIVE STREET
    SAINT LOUIS, MO
    ZIP 63103
  • Facility Phone: 314 371-6500
  • Facility Type: Other - OUTPATIENT BEHAVORIAL HEA
  • Facility Type: Waiver
  • Lab Director: BAILEY E. WAHLQUIST
  • NPI Number: 1639350614
  • Taxonomy: 101YM0800X - Counselor

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CLIA Record

Field Name Field Value
CLIA Number 26D2177026
LAB Type Other - OUTPATIENT BEHAVORIAL HEA
Facility Name PROVIDENT INC (DBA PROVIDENT BEHAVORIAL HEALTH)
Street 2650 OLIVE STREET
City SAINT LOUIS
State MO
ZIP 63103
Phone 314 371-6500
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 1/2/2024
Certificate Expiration Date 1/1/2026
Facility Type Other - OUTPATIENT BEHAVORIAL HEA
Lab Director BAILEY E. WAHLQUIST

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This page was last updated on: 3/20/2025