Basic Information
| Provider Information | |||||||||
| NPI: | 1588063408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WECKBACH | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3660 VISTA AVE | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149775110 | ||||||||
| FaxNumber: | 3149775119 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 S. GRAND | ||||||||
| Address2: | DOOR 3 | ||||||||
| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631046310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149775110 | ||||||||
| FaxNumber: | 3149777686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2014 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 22124 | CA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 2015026297 | MO | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.