Healthcare Provider Details

I. General information

NPI: 1902910300
Provider Name (Legal Business Name): MARY SAMPLES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 KING AVE
PORTAGEVILLE MO
63873-1378
US

IV. Provider business mailing address

1680 HWY 61
PORTAGEVILLE MO
63873
US

V. Phone/Fax

Practice location:
  • Phone: 573-379-5706
  • Fax: 573-379-5873
Mailing address:
  • Phone: 573-379-0357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2057
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number107513
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: