Healthcare Provider Details

I. General information

NPI: 1730078080
Provider Name (Legal Business Name): KALLIE FEDERHOFER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9544 MANCHESTER RD
SAINT LOUIS MO
63119-1313
US

IV. Provider business mailing address

3621 MARION LN
LAS CRUCES NM
88012-7579
US

V. Phone/Fax

Practice location:
  • Phone: 573-203-3699
  • Fax:
Mailing address:
  • Phone: 575-520-6074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2026010665
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: