Healthcare Provider Details

I. General information

NPI: 1629460845
Provider Name (Legal Business Name): MONET BEATTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9206 LACKLAND RD
SAINT LOUIS MO
63114-5413
US

IV. Provider business mailing address

9206 LACKLAND RD
SAINT LOUIS MO
63114-5413
US

V. Phone/Fax

Practice location:
  • Phone: 314-600-7055
  • Fax:
Mailing address:
  • Phone: 314-600-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number2011036013
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: