Healthcare Provider Details

I. General information

NPI: 1669430005
Provider Name (Legal Business Name): MARK EDWARD MURRAY MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7508 BIG BEND BLVD
SAINT LOUIS MO
63119-2104
US

IV. Provider business mailing address

7308 WALNUT DR
GODFREY IL
62035-2707
US

V. Phone/Fax

Practice location:
  • Phone: 314-647-4880
  • Fax:
Mailing address:
  • Phone: 618-466-6485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001359
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: