Provider Demographics
NPI:1417901885
Name:OLIVERI, MICHAEL V (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:V
Last Name:OLIVERI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17300 N OUTER 40 RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1364
Mailing Address - Country:US
Mailing Address - Phone:636-536-7878
Mailing Address - Fax:636-536-7871
Practice Address - Street 1:17300 N OUTER 40 RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1364
Practice Address - Country:US
Practice Address - Phone:636-536-7878
Practice Address - Fax:636-536-7871
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORO299103G00000X
MOR0299103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR96802Medicaid
MOMA2910Medicare UPIN