Provider Demographics
NPI:1043970551
Name:ANDERSON, MATTHEW NEIL (MED)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:NEIL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, PLPC
Mailing Address - Street 1:5859 S KINGSHIGHWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-3571
Mailing Address - Country:US
Mailing Address - Phone:314-669-6242
Mailing Address - Fax:
Practice Address - Street 1:3460 HAMPTON AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1938
Practice Address - Country:US
Practice Address - Phone:314-669-6242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-23
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
15470693OtherCAQH