MEDICARE: CALLIE MAE MATHIS

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	235Z00000X	Speech-Language Pathologist	2019046398	MO

General Provider Information

NPI Number	:	1528677887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALLIE MAE MATHIS

Provider Business Mailing Address
First Line	:	4359 TAFT AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-1533
Country	:	US
Telephone Number	:	314-752-2022
Fax Number	:

Provider Business Practice Location Address
First Line	:	4359 TAFT AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-1533
Country	:	US
Telephone Number	:	314-752-2022
Fax Number	:

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

Provider Enumeration Date	:	07/23/2020
Last Update Date	:	07/23/2020

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Directions to “ CALLIE MAE MATHIS ” Practice Location

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