Provider Demographics
NPI:1225424732
Name:ROBERTS, MARY
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHLEEN
Other - Last Name:MACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2310 HWY 94 S OUTER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-8301
Mailing Address - Country:US
Mailing Address - Phone:636-552-4275
Mailing Address - Fax:888-386-2172
Practice Address - Street 1:2310 HWY 94 S OUTER RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-8301
Practice Address - Country:US
Practice Address - Phone:636-552-4275
Practice Address - Fax:888-386-2172
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist