=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114164977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | URSULA WIESE MARSH PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2009
-----------------------------------------------------
Last Update Date | 11/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 219 CREEKSIDE OFFICE DRIVE
-----------------------------------------------------
City | WENTZVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63385-3290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-357-0136
-----------------------------------------------------
Fax | 636-639-1004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 COUNTRY RD P.O. BOX 186
-----------------------------------------------------
City | FORISTELL
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63348-1722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-332-6906
-----------------------------------------------------
Fax | 636-639-1004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 2007036957
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------