Provider Demographics
NPI:1902893589
Name:OBOWA, MARY C (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:OBOWA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12141 LADUE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8120
Mailing Address - Country:US
Mailing Address - Phone:314-336-1097
Mailing Address - Fax:314-878-4524
Practice Address - Street 1:12141 LADUE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8120
Practice Address - Country:US
Practice Address - Phone:314-336-1097
Practice Address - Fax:314-878-4524
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
MOCS001545101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO118671OtherBLUE CROSS BLUE SHIELD