Healthcare Provider Details

I. General information

NPI: 1770136046
Provider Name (Legal Business Name): LARA ALLISON MENKE BLOMGREN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12110 CLAYTON RD
SAINT LOUIS MO
63131-2599
US

IV. Provider business mailing address

5718 SOUTHWEST AVE
SAINT LOUIS MO
63139-1606
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-8100
  • Fax:
Mailing address:
  • Phone: 314-277-0736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2022022020
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: