Organization
MISSOURI SPEECH THERAPY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MARY R ETHRIDGE M.S., CCC-SLP (SPEECH/LANGUAGE PATHOLOGIST)
(417) 326-9464
Entity
Organization
Contact information
Practice address
1009 HWY B, BOLIVAR, MO 65613-8252
(417) 326-6754
Mailing address
4115 101ST RD, BOLIVAR, MO 65613-8608
(417) 326-9464
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
106670
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1134399710
MEDICAID WAIVER
MO
Enumeration date
05/29/2014
Last updated
12/18/2018
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