Provider Demographics
NPI:1760681779
Name:RUBY, MICHELLE RENE' (SLP)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RENE'
Last Name:RUBY
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 1:2840 DALTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1630
Mailing Address - Country:US
Mailing Address - Phone:314-645-7571
Mailing Address - Fax:
Practice Address - Street 1:3625 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-4048
Practice Address - Country:US
Practice Address - Phone:317-771-2990
Practice Address - Fax:317-771-7960
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006014641235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist