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General NPI Number Information
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NPI Number | 1215273990
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Entity Type | Organization
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Legal Business Name | TRICORE SPEECH LLC
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Dates
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Enumeration Date | 12/27/2012
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Last Update Date | 12/27/2012
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Provider Practice Location Address
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Address Line | 4491 BESSIE AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63115-2707
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Country | US
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Telephone | 314-660-1690
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Fax | 314-389-4820
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Provider Business Mailing Address
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Address Line | 4491 BESSIE AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63115-2707
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Country | US
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Telephone | 314-660-1690
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Fax | 314-389-4820
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Authorized Official
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Title or Position | SPEECH LANGUAGE PATHOLOGIST/MANAGER
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Name | MRS. ANDREA DENICE CAMPBELL-WILLIAMS
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Credential | CCC-SLP
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Telephone | 314-660-1690
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 112012
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License Number State | MO
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