Healthcare Provider Details

I. General information

NPI: 1992878847
Provider Name (Legal Business Name): ROGER LOUIS GENNARI PHD CLINICAL PSYCHOL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SOUTH MERAMEC SUITE 432T
CLAYTON MI
63105
US

IV. Provider business mailing address

225 SOUTH MERAMEC SUITE 432T
CLAYTON MI
63105
US

V. Phone/Fax

Practice location:
  • Phone: 314-721-4975
  • Fax: 314-721-6778
Mailing address:
  • Phone: 314-721-4975
  • Fax: 314-721-6778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberR0043
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: