Healthcare Provider Details

I. General information

NPI: 1255489902
Provider Name (Legal Business Name): MATTHEW DOUGLAS KLIETHERMES PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY BLVD WEINMAN BLDG-UPPER LEVEL
SAINT LOUIS MO
63121-4400
US

IV. Provider business mailing address

12112 JEANNETTE MARY DR
MARYLAND HEIGHTS MO
63043-4221
US

V. Phone/Fax

Practice location:
  • Phone: 314-516-7231
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2004024732
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: