MEDICARE: MRS. BRANDI MICHELLE WALLGREN M.A, CF-SLP

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	235Z00000X	Speech-Language Pathologist	2016026106	MO

General Provider Information

NPI Number	:	1275089336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRANDI MICHELLE WALLGREN M.A, CF-SLP

Provider Business Mailing Address
First Line	:	1105 BELLA VISTA DR
Second Line	:
City	:	JACKSON
State	:	MO
Zip	:	63755-7850
Country	:	US
Telephone Number	:	573-803-7434
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 S GARRISON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-2538
Country	:	US
Telephone Number	:	314-340-5902
Fax Number	:

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

Provider Enumeration Date	:	08/29/2016
Last Update Date	:	08/29/2016

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