Provider Demographics
NPI:1205621380
Name:GREEN, MAKAYLA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 TRIAD CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ST. CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63376
Mailing Address - Country:US
Mailing Address - Phone:417-631-3063
Mailing Address - Fax:
Practice Address - Street 1:1404 TRIAD CENTER DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-7351
Practice Address - Country:US
Practice Address - Phone:314-254-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023032981235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist