Basic Information
| Provider Information | |||||||||
| NPI: | 1851403190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TERRITO | ||||||||
| FirstName: | CARLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 748 STONEBLUFF CT | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630054868 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1224 GRAHAM RD | ||||||||
| Address2: | SUITE 3011 | ||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630318028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148391211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0107X | 1999138138 | MO | Y |
ID Information
| ID | Type | State | Issuer | Description | 20483308 | 05 | MO | MEDICAID |