Healthcare Provider Details

I. General information

NPI: 1295233468
Provider Name (Legal Business Name): MATTHEW MARSHALL NMT-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 HAMPTON AVE
SAINT LOUIS MO
63139-2935
US

IV. Provider business mailing address

9063 BURTON AVE
OVERLAND MO
63114-4825
US

V. Phone/Fax

Practice location:
  • Phone: 314-647-2200
  • Fax: 314-647-4172
Mailing address:
  • Phone: 314-409-0421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code246Y00000X
TaxonomyHealth Information Specialist/Technologist
License Number
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: