Healthcare Provider Details

I. General information

NPI: 1083837215
Provider Name (Legal Business Name): REGINA MARIE NOLAN M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 FOXVIEW TER
BALLWIN MO
63011-4316
US

IV. Provider business mailing address

1208 FOXVIEW TER
BALLWIN MO
63011-4316
US

V. Phone/Fax

Practice location:
  • Phone: 314-719-7140
  • Fax:
Mailing address:
  • Phone: 314-719-7140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number109811
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number109811
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: