Provider Demographics
NPI:1376192849
Name:SHADWELL, MICHAEL STUART
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STUART
Last Name:SHADWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3814 WILMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3221
Mailing Address - Country:US
Mailing Address - Phone:312-420-9119
Mailing Address - Fax:
Practice Address - Street 1:3814 WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-3221
Practice Address - Country:US
Practice Address - Phone:312-420-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-08
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-19-89344106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR181353039OtherDRIVERS LICENSE