Provider Demographics
NPI:1790811636
Name:MCDERMOTT, REBECCA A (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6223 SOUTHWOOD AVE
Mailing Address - Street 2:#1N.
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3255
Mailing Address - Country:US
Mailing Address - Phone:314-726-4681
Mailing Address - Fax:
Practice Address - Street 1:1809 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5065
Practice Address - Country:US
Practice Address - Phone:636-532-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100164235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS100164OtherMISSOURI LICENSE