Healthcare Provider Details

I. General information

NPI: 1225424732
Provider Name (Legal Business Name): MS. MARY ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY KATHLEEN MACON

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 HWY 94 S OUTER RD
SAINT CHARLES MO
63303-8301
US

IV. Provider business mailing address

2310 HWY 94 S OUTER RD
SAINT CHARLES MO
63303-8301
US

V. Phone/Fax

Practice location:
  • Phone: 636-552-4275
  • Fax: 888-386-2172
Mailing address:
  • Phone: 636-552-4275
  • Fax: 888-386-2172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: