Provider Demographics
NPI:1104483429
Name:WILLARD, MARY KATHERINE (MSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHERINE
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:WILLARD
Other - Last Name:VIRANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:10 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1304
Mailing Address - Country:US
Mailing Address - Phone:978-257-0184
Mailing Address - Fax:
Practice Address - Street 1:7750 CLAYTON RD STE 310
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1341
Practice Address - Country:US
Practice Address - Phone:314-858-6884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190075511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical