Provider Demographics
NPI:1407092067
Name:OBERMARK, MICHELLE L (MS, CCC-SLP/L)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:L
Last Name:OBERMARK
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6365 MEADOWLAKE DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4131
Mailing Address - Country:US
Mailing Address - Phone:314-402-8499
Mailing Address - Fax:
Practice Address - Street 1:801 N 11TH ST
Practice Address - Street 2:MEDICAID DEPARTMENT
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1015
Practice Address - Country:US
Practice Address - Phone:314-345-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-31
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008020882235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist