Provider Demographics
NPI:1073576286
Name:ST.CLAIR, MARY NYE (LCSW, ATR-BC, CGP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NYE
Last Name:ST.CLAIR
Suffix:
Gender:F
Credentials:LCSW, ATR-BC, CGP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:NYE
Other - Last Name:GOTHBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:7750 CLAYTON RD
Mailing Address - Street 2:SUITE 308 A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1353
Mailing Address - Country:US
Mailing Address - Phone:314-644-4422
Mailing Address - Fax:
Practice Address - Street 1:7750 CLAYTON RD
Practice Address - Street 2:SUITE 308 A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1353
Practice Address - Country:US
Practice Address - Phone:314-644-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW000038381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209651OtherANTHEM BCBS
MO490614104Medicaid
MO490614104Medicaid