Full Potential Residential Services, LLC

Primary specialty

Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X

License

2006031224 Issued in MO

Legal business name

FULL POTENTIAL RESIDENTIAL SERVICES, LLC

Practice address

8208 Page Ave
Saint Louis, MO 63130-1115

Phone

(314) 839-9157

Fax

(314) 839-9157

NPI assigned

Aug 28, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Demetra Evon Roberts, LIC. SOCIAL WORKER

Title

Administrator

Phone

(314) 839-9157

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1219881600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1219881600000",
    "number": "1730337114",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2335 INDIANCUP DR",
            "city": "FLORISSANT",
            "state": "MO",
            "postal_code": "630331736",
            "telephone_number": "314-839-9157"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8208 PAGE AVE",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631301115",
            "telephone_number": "314-839-9157",
            "fax_number": "314-839-9157"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FULL POTENTIAL RESIDENTIAL SERVICES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-28",
        "last_updated": "2008-08-28",
        "status": "A",
        "authorized_official_last_name": "ROBERTS",
        "authorized_official_first_name": "DEMETRA",
        "authorized_official_middle_name": "EVON",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "314-839-9157",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "LIC. SOCIAL WORKER"
    },
    "taxonomies": [
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "MO",
            "license": "2006031224",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Saint Louis, MO
• Providers in Saint Louis, MO by specialty
• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.