Healthcare Provider Details

I. General information

NPI: 1104013689
Provider Name (Legal Business Name): TAMMY ANNE MARTIELLI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS TAMMY ANNE MANDERNACH

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
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 Number2009010486
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2009010486
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: