Healthcare Provider Details

I. General information

NPI: 1972106821
Provider Name (Legal Business Name): MARY CATHERINE SAMUEL MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS MARY CATHERINE MCALLISTER

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6929 WISE AVE
SAINT LOUIS MO
63139-3731
US

IV. Provider business mailing address

6929 WISE AVE
SAINT LOUIS MO
63139-3731
US

V. Phone/Fax

Practice location:
  • Phone: 314-297-8008
  • Fax:
Mailing address:
  • Phone: 314-312-2984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number105223
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: