Healthcare Provider Details

I. General information

NPI: 1891703435
Provider Name (Legal Business Name): HENRY HUMMERT PH D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 OLD FRONTENAC SQ STE 201
SAINT LOUIS MO
63131-2754
US

IV. Provider business mailing address

745 OLD FRONTENAC SQ STE 201
SAINT LOUIS MO
63131-2754
US

V. Phone/Fax

Practice location:
  • Phone: 314-993-3323
  • Fax: 314-993-5424
Mailing address:
  • Phone: 314-993-3323
  • Fax: 314-993-5424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPYR0188
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: