Healthcare Provider Details

I. General information

NPI: 1043814874
Provider Name (Legal Business Name): THE NEUROPSYCHOLOGY CENTER OF ST. LOUIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 N NEW BALLAS RD STE 290
CREVE COEUR MO
63141-6852
US

IV. Provider business mailing address

425 N NEW BALLAS RD STE 290
CREVE COEUR MO
63141-6852
US

V. Phone/Fax

Practice location:
  • Phone: 314-324-3800
  • Fax: 314-260-7676
Mailing address:
  • Phone: 314-324-3800
  • Fax: 314-260-7676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. TAMMY A MARTIELLI
Title or Position: NEUROPSYCHOLOGIST/MEMBER
Credential: PH.D.
Phone: 314-324-3800