Healthcare Provider Details

I. General information

NPI: 1750151791
Provider Name (Legal Business Name): MARY KATHERINE MAZZOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7432 MARILLAC DR
SAINT LOUIS MO
63121-4744
US

IV. Provider business mailing address

221 MONTROSE CT
O FALLON MO
63368-7726
US

V. Phone/Fax

Practice location:
  • Phone: 314-495-8430
  • Fax: 314-689-0211
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number2023034141
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: