Healthcare Provider Details

I. General information

NPI: 1194826578
Provider Name (Legal Business Name): ANTHONY DALE UDZIELA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13354 MANCHESTER RD STE 220
SAINT LOUIS MO
63131-1709
US

IV. Provider business mailing address

13354 MANCHESTER RD STE 220
SAINT LOUIS MO
63131-1709
US

V. Phone/Fax

Practice location:
  • Phone: 314-614-9730
  • Fax: 314-692-7929
Mailing address:
  • Phone: 314-614-9730
  • Fax: 314-692-7929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY01064
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: