Healthcare Provider Details

I. General information

NPI: 1245692854
Provider Name (Legal Business Name): MARY E COLIZZA MAC, PLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EXECUTIVE PARKWAY DR STE 106
SAINT LOUIS MO
63141-6369
US

IV. Provider business mailing address

1000 EXECUTIVE PARKWAY DR STE 106
SAINT LOUIS MO
63141-6369
US

V. Phone/Fax

Practice location:
  • Phone: 314-469-5522
  • Fax: 314-469-5504
Mailing address:
  • Phone: 314-469-5522
  • Fax: 314-469-5504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2013041573
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: