Healthcare Provider Details

I. General information

NPI: 1962959957
Provider Name (Legal Business Name): COLLEEN MARIE HARBAUGH M.S.CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

565 VOSSHILL DR
BALLWIN MO
63021-6237
US

V. Phone/Fax

Practice location:
  • Phone: 636-695-2070
  • Fax:
Mailing address:
  • Phone: 314-803-1674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2003009191
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: