MEDICARE: MARY E WENOM LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW005179	MO

General Provider Information

NPI Number	:	1073521639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY E WENOM LCSW

Provider Business Mailing Address
First Line	:	13029 TWIN MEADOWS CT
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-1804
Country	:	US
Telephone Number	:	314-434-5658
Fax Number	:

Provider Business Practice Location Address
First Line	:	1272 JUNGERMANN RD STE C
Second Line	:
City	:	SAINT PETERS
State	:	MO
Zip	:	63376-6968
Country	:	US
Telephone Number	:	636-928-5800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	02/13/2009

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