1821400474 NPI number — MISSOURI SPEECH THERAPY

Table of content: (NPI 1821400474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821400474 NPI number — MISSOURI SPEECH THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSOURI SPEECH THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821400474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4115 101ST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLIVAR
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65613-8608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-326-9464
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009 HWY B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOLIVAR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65613-8252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-326-6754
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ETHRIDGE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
SPEECH/LANGUAGE PATHOLOGIST
Authorized Official Telephone Number:
417-326-9464

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  106670 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1134399710 . This is a "MEDICAID WAIVER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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