Healthcare Provider Details

I. General information

NPI: 1437049020
Provider Name (Legal Business Name): KATIE MYROLD CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

663 COEUR DE ROYALE DR APT D
SAINT LOUIS MO
63141-7043
US

IV. Provider business mailing address

663 COEUR DE ROYALE DR APT D
SAINT LOUIS MO
63141-7043
US

V. Phone/Fax

Practice location:
  • Phone: 636-299-0075
  • Fax:
Mailing address:
  • Phone: 636-299-0075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number86686
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: