Provider Demographics
NPI:1508929308
Name:BACKER-CONKLIN, MARY S (SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:S
Last Name:BACKER-CONKLIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 LONG RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1235
Mailing Address - Country:US
Mailing Address - Phone:636-733-3330
Mailing Address - Fax:636-733-3332
Practice Address - Street 1:150 LONG RD
Practice Address - Street 2:SUITE 150
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1235
Practice Address - Country:US
Practice Address - Phone:636-733-3330
Practice Address - Fax:636-733-3332
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01075235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist