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General NPI Number Information
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NPI Number | 1073521639
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Entity Type | Individual
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Provider Name | MARY E WENOM LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/03/2006
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Last Update Date | 02/13/2009
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Provider Practice Location Address
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Address Line | 1272 JUNGERMANN RD STE C
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City | SAINT PETERS
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State | MO
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Zip | 63376-6968
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Country | US
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Telephone | 636-928-5800
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Fax |
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Provider Business Mailing Address
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Address Line | 13029 TWIN MEADOWS CT
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City | SAINT LOUIS
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State | MO
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Zip | 63146-1804
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Country | US
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Telephone | 314-434-5658
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW005179
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License Number State | MO
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