Provider Demographics
NPI:1386627941
Name:MELTZER, THEODORE (MA)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:
Last Name:MELTZER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 CRAIG RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7138
Mailing Address - Country:US
Mailing Address - Phone:314-997-6463
Mailing Address - Fax:314-997-4423
Practice Address - Street 1:777 CRAIG RD
Practice Address - Street 2:SUITE 120
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7138
Practice Address - Country:US
Practice Address - Phone:314-997-6463
Practice Address - Fax:314-997-4423
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01021103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000024097Medicare PIN