Healthcare Provider Details

I. General information

NPI: 1154089985
Provider Name (Legal Business Name): MADELINE INCE MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2021
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 PARK AVE FL 2
SAINT LOUIS MO
63110-2514
US

IV. Provider business mailing address

3800 PARK AVE FL 2
SAINT LOUIS MO
63110-2514
US

V. Phone/Fax

Practice location:
  • Phone: 314-678-6648
  • Fax: 314-268-4028
Mailing address:
  • Phone: 314-678-6648
  • Fax: 314-268-4028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2019018004
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: