Healthcare Provider Details

I. General information

NPI: 1568633261
Provider Name (Legal Business Name): TERRY LAROYCE PAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8390 DELMAR BLVD SUITE 210
SAINT LOUIS MO
63124-2117
US

IV. Provider business mailing address

8390 DELMAR BLVD SUITE 210
SAINT LOUIS MO
63124-2117
US

V. Phone/Fax

Practice location:
  • Phone: 314-692-9010
  • Fax: 314-692-9014
Mailing address:
  • Phone: 314-692-9010
  • Fax: 314-692-9014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number000732
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: