MEDICARE: TOMERO FREDALE MCCLENTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1154279776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOMERO FREDALE MCCLENTON

Provider Business Mailing Address
First Line	:	4647 HEIDELBERG AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63123-5822
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4647 HEIDELBERG AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63123-5822
Country	:	US
Telephone Number	:	573-620-0976
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2026
Last Update Date	:	03/19/2026

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Directions to “ TOMERO FREDALE MCCLENTON ” Practice Location

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