Provider Demographics
NPI:1558682534
Name:NEUROPSYCHOLOGY OF ST. LOUIS, LLC
Entity Type:Organization
Organization Name:NEUROPSYCHOLOGY OF ST. LOUIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:314-757-4969
Mailing Address - Street 1:9890 CLAYTON RD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1685
Mailing Address - Country:US
Mailing Address - Phone:314-222-5872
Mailing Address - Fax:
Practice Address - Street 1:9890 CLAYTON RD
Practice Address - Street 2:SUITE 136
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-1685
Practice Address - Country:US
Practice Address - Phone:314-222-5872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-14
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009015463103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3277Medicare UPIN