Healthcare Provider Details

I. General information

NPI: 1730695362
Provider Name (Legal Business Name): CURATORS OF THE UNIVERSITY OF MISSOURI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12837 FLUSHING MEADOWS DRIVE SUTIE 220
TOWN AND COUNTRY MO
63131
US

IV. Provider business mailing address

12837 FLUSHING MEADOWS DRIVE SUITE 220
TOWN AND COUNTRY MO
63131
US

V. Phone/Fax

Practice location:
  • Phone: 314-516-4357
  • Fax: 314-516-5347
Mailing address:
  • Phone: 314-516-6275
  • Fax: 314-516-5347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL ROLAND LEVEQUE
Title or Position: ASSISTANT DIRECTOR
Credential: PSY.D.
Phone: 314-516-6275