Healthcare Provider Details

I. General information

NPI: 1720780588
Provider Name (Legal Business Name): BAILEY CHAKLOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12380 DE PAUL DR
BRIDGETON MO
63044-2511
US

IV. Provider business mailing address

1210 OXFORD HILL CT APT 6
SAINT LOUIS MO
63146-5718
US

V. Phone/Fax

Practice location:
  • Phone: 314-447-9710
  • Fax:
Mailing address:
  • Phone: 618-578-8619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2022031592
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: