Healthcare Provider Details

I. General information

NPI: 1386776243
Provider Name (Legal Business Name): BROOKE A SHAW BA, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 09/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10030 MANCHESTER RD
SAINT LOUIS MO
63122-1832
US

IV. Provider business mailing address

PO BOX 510384
SAINT LOUIS MO
63151-0384
US

V. Phone/Fax

Practice location:
  • Phone: 314-714-4137
  • Fax:
Mailing address:
  • Phone: 314-714-4137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: