Healthcare Provider Details

I. General information

NPI: 1962555979
Provider Name (Legal Business Name): ANTHONY THOMAS BALISTRIERI L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 WALNUT CRST
MARTHASVILLE MO
63357-1508
US

IV. Provider business mailing address

44 WALNUT CRST
MARTHASVILLE MO
63357-1508
US

V. Phone/Fax

Practice location:
  • Phone: 314-420-6823
  • Fax: 363-433-2683
Mailing address:
  • Phone: 314-420-6823
  • Fax: 363-433-2683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number000669
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: