Healthcare Provider Details

I. General information

NPI: 1710286182
Provider Name (Legal Business Name): KRYSTEN MCGOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 MCMENAMY RD
SAINT PETERS MO
63376-1510
US

IV. Provider business mailing address

1306 AVONDALE SPRING DR
O FALLON MO
63368-7993
US

V. Phone/Fax

Practice location:
  • Phone: 636-397-3111
  • Fax:
Mailing address:
  • Phone: 64-531-5402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberA01821
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2025031413
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA12918
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: