Provider Demographics
NPI:1730631508
Name:CALICUTT, BOBIE
Entity type:Individual
Prefix:
First Name:BOBIE
Middle Name:
Last Name:CALICUTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 CRAIGSHIRE RD STE 420F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4043
Mailing Address - Country:US
Mailing Address - Phone:816-400-4276
Mailing Address - Fax:314-887-7004
Practice Address - Street 1:2055 CRAIGSHIRE RD STE 420F
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4043
Practice Address - Country:US
Practice Address - Phone:816-400-4276
Practice Address - Fax:314-887-7004
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO172V00000X
MOT208137023172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1730631508Medicaid