Provider Demographics
NPI:1972106821
Name:SAMUEL, MARY CATHERINE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CATHERINE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:MCALLISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6929 WISE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3731
Mailing Address - Country:US
Mailing Address - Phone:314-312-2984
Mailing Address - Fax:
Practice Address - Street 1:6929 WISE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-3731
Practice Address - Country:US
Practice Address - Phone:314-297-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105223235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty