Healthcare Provider Details

I. General information

NPI: 1326313123
Provider Name (Legal Business Name): MRS. LISA INCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 S TAYLOR AVE
SAINT LOUIS MO
63110-1567
US

IV. Provider business mailing address

503 TERRINGTON DR
BALLWIN MO
63021-4467
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-0132
  • Fax:
Mailing address:
  • Phone: 636-386-5170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number0484537
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: