Healthcare Provider Details

I. General information

NPI: 1770913089
Provider Name (Legal Business Name): MATTHEW CHARLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD STE 364B
SAINT LOUIS MO
63128-2141
US

IV. Provider business mailing address

10004 KENNERLY RD STE 364B
SAINT LOUIS MO
63128-2141
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-4429
  • Fax: 314-525-7260
Mailing address:
  • Phone: 314-525-4429
  • Fax: 314-525-7260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number2013037719
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2013037719
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: