Healthcare Provider Details

I. General information

NPI: 1255842704
Provider Name (Legal Business Name): MATTHEW WILLIAM VAPOREAN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 S BROADWAY
SAINT LOUIS MO
63118-4608
US

IV. Provider business mailing address

3800 S BROADWAY
SAINT LOUIS MO
63118-4608
US

V. Phone/Fax

Practice location:
  • Phone: 314-772-2205
  • Fax:
Mailing address:
  • Phone: 314-772-2205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.102528
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2016029104
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: