MEDICARE: ST CHARLES WEST PSYCHOLOGICAL

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1538243571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST CHARLES WEST PSYCHOLOGICAL

Provider Business Mailing Address
First Line	:	600 MEDICAL DR STE 205
Second Line	:
City	:	WENTZVILLE
State	:	MO
Zip	:	63385-3426
Country	:	US
Telephone Number	:	314-432-2580
Fax Number	:	314-432-0223

Provider Business Practice Location Address
First Line	:	600 MEDICAL DR STE 205
Second Line	:
City	:	WENTZVILLE
State	:	MO
Zip	:	63385-3426
Country	:	US
Telephone Number	:	314-432-2580
Fax Number	:	314-432-0223

Authorized Official
Title or Position	:	ACCT MANAGER
Name	:	VALERIE ANDRADE
Credential	:
Telephone Number	:	314-432-2580

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	08/31/2009

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Directions to “ST CHARLES WEST PSYCHOLOGICAL ” Practice Location

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