Healthcare Provider Details

I. General information

NPI: 1265755037
Provider Name (Legal Business Name): MATRIX PSYCHIATRIC HOME AND HEALTH CARE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 03/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 VILLAS ESTATES DR
FENTON MO
63026-3284
US

IV. Provider business mailing address

1423 VILLAS ESTATES DR
FENTON MO
63026-3284
US

V. Phone/Fax

Practice location:
  • Phone: 314-954-5568
  • Fax:
Mailing address:
  • Phone: 314-954-5568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number132832
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number132832
License Number StateMO

VIII. Authorized Official

Name: MS. TAMMIE MARIE AUER
Title or Position: OWNER
Credential: R.N.
Phone: 314-954-5568