Healthcare Provider Details

I. General information

NPI: 1760920052
Provider Name (Legal Business Name): MICHELLE FLYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12110 CLAYTON RD
SAINT LOUIS MO
63131-2516
US

IV. Provider business mailing address

1550 DERHAKE RD
FLORISSANT MO
63033-6416
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-8150
  • Fax:
Mailing address:
  • Phone: 314-989-7260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2016014716
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: