Healthcare Provider Details

I. General information

NPI: 1114396330
Provider Name (Legal Business Name): MICHAEL S GAFFREY PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 FOREST PARK AVE STE 2600 STE 2600
SAINT LOUIS MO
63108-2212
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8134
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-1700
  • Fax: 314-286-1799
Mailing address:
  • Phone: 314-286-1700
  • Fax: 314-286-1799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2010039559
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: