Healthcare Provider Details

I. General information

NPI: 1740566041
Provider Name (Legal Business Name): EVANGELINE MAE BAUER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63139-1006
US

IV. Provider business mailing address

4002 BOTANICAL AVE
SAINT LOUIS MO
63110-3906
US

V. Phone/Fax

Practice location:
  • Phone: 314-802-8805
  • Fax:
Mailing address:
  • Phone: 708-805-4363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2011034908
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: