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General NPI Number Information
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NPI Number | 1821400474
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Entity Type | Organization
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Legal Business Name | MISSOURI SPEECH THERAPY
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Dates
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Enumeration Date | 05/29/2014
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Last Update Date | 12/18/2018
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Provider Practice Location Address
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Address Line | 1009 HWY B
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City | BOLIVAR
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State | MO
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Zip | 65613-8252
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Country | US
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Telephone | 417-326-6754
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Fax |
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Provider Business Mailing Address
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Address Line | 4115 101ST RD
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City | BOLIVAR
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State | MO
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Zip | 65613-8608
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Country | US
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Telephone | 417-326-9464
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Fax |
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Authorized Official
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Title or Position | SPEECH/LANGUAGE PATHOLOGIST
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Name | MRS. MARY R ETHRIDGE
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Credential | M.S., CCC-SLP
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Telephone | 417-326-9464
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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 | 106670
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License Number State | MO
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