Healthcare Provider Details

I. General information

NPI: 1083708820
Provider Name (Legal Business Name): MARY LYNN PALOMBO L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#1 JEFFERSON BARRACKS DRIVE
ST. LOUIS MO
63125
US

IV. Provider business mailing address

1945 FOREST HAVEN DRIVE
IMPERIAL MO
63052
US

V. Phone/Fax

Practice location:
  • Phone: 314-894-6547
  • Fax:
Mailing address:
  • Phone: 314-894-6547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004774
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: