Provider Demographics
NPI:1275955163
Name:FELDEWERTH, SANDRA MICHELLE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MICHELLE
Last Name:FELDEWERTH
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 1:17119 PIKE 135
Mailing Address - Street 2:
Mailing Address - City:LOUISIANA
Mailing Address - State:MO
Mailing Address - Zip Code:63353-3500
Mailing Address - Country:US
Mailing Address - Phone:574-754-2675
Mailing Address - Fax:
Practice Address - Street 1:2560 METRO BLVD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-2417
Practice Address - Country:US
Practice Address - Phone:314-715-3855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013045011103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst