Healthcare Provider Details

I. General information

NPI: 1972811149
Provider Name (Legal Business Name): MARY KATHERINE GOVERNAL C.O.T.A./L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 HARBOR BEND CT
LAKE ST LOUIS MO
63367-1478
US

IV. Provider business mailing address

2 HARBOR BEND CT SUITE 102
LAKE ST LOUIS MO
63367-1478
US

V. Phone/Fax

Practice location:
  • Phone: 636-965-2070
  • Fax: 636-695-2080
Mailing address:
  • Phone: 636-695-2070
  • Fax: 636-695-2080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2009014323
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: