Healthcare Provider Details

I. General information

NPI: 1760200992
Provider Name (Legal Business Name): TAYLOR NICOLE KLOCKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 01/11/2026
Certification Date: 01/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N BAKER ST
EDINA MO
63537-4320
US

IV. Provider business mailing address

805 N BAKER ST
EDINA MO
63537-4320
US

V. Phone/Fax

Practice location:
  • Phone: 573-719-0971
  • Fax:
Mailing address:
  • Phone: 573-719-0971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: