MEDICARE: MS. MARYANNE MICA MSW

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	000988	MO

General Provider Information

NPI Number	:	1205079340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARYANNE MICA MSW

Provider Business Mailing Address
First Line	:	136 HORSESHOE DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-3714
Country	:	US
Telephone Number	:	314-800-8747
Fax Number	:

Provider Business Practice Location Address
First Line	:	136 HORSESHOE DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-3714
Country	:	US
Telephone Number	:	314-800-8747
Fax Number	:

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

Provider Enumeration Date	:	04/17/2009
Last Update Date	:	04/17/2009

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