MEDICARE: MS. AMY KATHLEEN VESCOVO

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

General Provider Information

NPI Number	:	1437172319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMY KATHLEEN VESCOVO

Provider Business Mailing Address
First Line	:	1430 OLIVE ST
Second Line	:	SUITE 400
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-2303
Country	:	US
Telephone Number	:	314-206-3436
Fax Number	:	314-206-3992

Provider Business Practice Location Address
First Line	:	3165 MCKELVEY RD
Second Line	:	SUITE 200
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2550
Country	:	US
Telephone Number	:	314-206-3436
Fax Number	:	314-206-3992

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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