MEDICARE: MICHAEL STUART SHADWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-19-89344	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R181353039	OTHER	MO	DRIVERS LICENSE

General Provider Information

NPI Number	:	1376192849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL STUART SHADWELL

Provider Business Mailing Address
First Line	:	3814 WILMINGTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-3221
Country	:	US
Telephone Number	:	312-420-9119
Fax Number	:

Provider Business Practice Location Address
First Line	:	3814 WILMINGTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-3221
Country	:	US
Telephone Number	:	312-420-9119
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2019
Last Update Date	:	09/08/2019

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Directions to “ MICHAEL STUART SHADWELL ” Practice Location

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