Healthcare Provider Details

I. General information

NPI: 1205512969
Provider Name (Legal Business Name): TWMK2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W LOCKWOOD AVE STE 204
SAINT LOUIS MO
63119-2945
US

IV. Provider business mailing address

451 ALICE AVE
KIRKWOOD MO
63122-6304
US

V. Phone/Fax

Practice location:
  • Phone: 773-672-2342
  • Fax: 773-825-8219
Mailing address:
  • Phone: 773-677-0937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. TRAVIS WOOD MUNNERLYN
Title or Position: OWNER/PRESIDENT
Credential: PSYD
Phone: 773-677-0937