Provider Demographics
NPI:1104013689
Name:MARTIELLI, TAMMY ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:ANNE
Last Name:MARTIELLI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MISS
Other - First Name:TAMMY
Other - Middle Name:ANNE
Other - Last Name:MANDERNACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:425 N NEW BALLAS RD STE 290
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6852
Mailing Address - Country:US
Mailing Address - Phone:314-324-3800
Mailing Address - Fax:314-260-7676
Practice Address - Street 1:425 N NEW BALLAS RD STE 290
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6852
Practice Address - Country:US
Practice Address - Phone:314-324-3800
Practice Address - Fax:314-260-7676
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009010486103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical