Healthcare Provider Details

I. General information

NPI: 1093905671
Provider Name (Legal Business Name): ELIZABETH MARIE VACCARO L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12141 LADUE RD
SAINT LOUIS MO
63141-8120
US

IV. Provider business mailing address

12141 LADUE RD
SAINT LOUIS MO
63141-8120
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-4340
  • Fax: 314-878-4524
Mailing address:
  • Phone: 314-878-4340
  • Fax: 314-878-4524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2005009317
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: