=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720533763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINA VERMAUX MS, CCC-SLP/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2016
-----------------------------------------------------
Last Update Date | 08/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6113 KEEBLER OAKS DR
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62062-6464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-724-9724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6113 KEEBLER OAKS DR
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62062-6464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-724-9724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 146.006805
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2007033589
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------