Provider Demographics
NPI:1952385585
Name:MARYGROVE
Entity Type:Organization
Organization Name:MARYGROVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NEGRI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-830-6201
Mailing Address - Street 1:2705 MULLANPHY LN
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-3727
Mailing Address - Country:US
Mailing Address - Phone:314-830-6201
Mailing Address - Fax:314-830-6258
Practice Address - Street 1:2705 MULLANPHY LN
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-3727
Practice Address - Country:US
Practice Address - Phone:314-830-6201
Practice Address - Fax:314-830-6258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO486680918FOSMedicare UPIN
MO13295Medicare UPIN
MO425834702Medicare UPIN