Healthcare Provider Details

I. General information

NPI: 1780887455
Provider Name (Legal Business Name): MARILYN J FIRESTONE M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8157 KINGSBURY BLVD
SAINT LOUIS MO
63105-3705
US

IV. Provider business mailing address

8157 KINGSBURY BLVD
SAINT LOUIS MO
63105-3705
US

V. Phone/Fax

Practice location:
  • Phone: 314-727-8657
  • Fax:
Mailing address:
  • Phone: 314-727-8657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number2007014828
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: