Provider Demographics
NPI:1093375230
Name:ST LOUIS, MAXINE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:ST LOUIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 BOSTON RD FL 4
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-4945
Mailing Address - Country:US
Mailing Address - Phone:718-589-1590
Mailing Address - Fax:
Practice Address - Street 1:1619 BOSTON RD FL 4
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-4945
Practice Address - Country:US
Practice Address - Phone:718-589-1590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY028795OtherDEPARTMENT OF EDUCATION