Healthcare Provider Details

I. General information

NPI: 1003581943
Provider Name (Legal Business Name): SARAH HELENE GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S BROADWAY
SAINT LOUIS MO
63111-2015
US

IV. Provider business mailing address

12215 FOXPOINT DR
MARYLAND HEIGHTS MO
63043-2109
US

V. Phone/Fax

Practice location:
  • Phone: 314-752-0000
  • Fax:
Mailing address:
  • Phone: 314-629-2370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2021032003
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: