Provider Demographics
NPI:1639509995
Name:SLADE, MIKE
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:SLADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CITYPLACE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 CITYPLACE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7096
Practice Address - Country:US
Practice Address - Phone:636-220-6334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004013225XR0403X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility