Provider Demographics
NPI:1699515767
Name:PATTERSON, MIA KELLY (MS, CF-SLP)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:KELLY
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:KELLY
Other - Last Name:PATTERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CF-SLP
Mailing Address - Street 1:1 BRAQUEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6403
Mailing Address - Country:US
Mailing Address - Phone:314-593-0834
Mailing Address - Fax:
Practice Address - Street 1:12563 VILLAGE CIRCLE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1758
Practice Address - Country:US
Practice Address - Phone:314-593-0834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty