Healthcare Provider Details

I. General information

NPI: 1740562651
Provider Name (Legal Business Name): MADELEINE KAY VATTEROTT-MORI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 WELDON SPRING HEIGHTS DR.
ST. CHARLES MO
63304-5623
US

IV. Provider business mailing address

21 WELDON SPRING HEIGHTS DR.
ST. CHARLES MO
63304-5623
US

V. Phone/Fax

Practice location:
  • Phone: 636-395-3460
  • Fax: 636-244-3164
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number01400
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number01400
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2012029564
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: