Healthcare Provider Details

I. General information

NPI: 1972641108
Provider Name (Legal Business Name): LANDY MAURER WEDLOCK MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 S SAPPINGTON RD
SAINT LOUIS MO
63122-6548
US

IV. Provider business mailing address

627 S SAPPINGTON RD
SAINT LOUIS MO
63122-6548
US

V. Phone/Fax

Practice location:
  • Phone: 314-740-1331
  • Fax:
Mailing address:
  • Phone: 314-740-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1999140934
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: