Healthcare Provider Details

I. General information

NPI: 1962685826
Provider Name (Legal Business Name): JULIE MARIE MASTNAK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#1 JEFFERSON BARRACKS DRIVE VETERANS AFFAIRS MEDICAL CENTER - JB DIVISION
SAINT LOUIS MO
63125
US

IV. Provider business mailing address

#1 JEFFERSON BARRACKS DRIVE VETERANS AFFAIRS MEDICAL CENTER - JB DIVISION
SAINT LOUIS MO
63125
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax: 314-845-5016
Mailing address:
  • Phone: 314-652-4100
  • Fax: 314-845-5016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2006035362
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: