Healthcare Provider Details

I. General information

NPI: 1053152892
Provider Name (Legal Business Name): MADMAR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 FERN RIDGE PKWY STE 110
SAINT LOUIS MO
63141-4405
US

IV. Provider business mailing address

1215 FERN RIDGE PKWY STE 110
SAINT LOUIS MO
63141-4405
US

V. Phone/Fax

Practice location:
  • Phone: 314-275-8599
  • Fax:
Mailing address:
  • Phone: 314-275-8599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: STEVE MISKOVIC
Title or Position: OWNER
Credential: MSW, LCSW
Phone: 314-971-7595