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General NPI Number Information
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NPI Number | 1790994309
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Entity Type | Individual
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Provider Name | MICHAEL G.S. GOTTFRIED PH.D.
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Gender | Male
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 01/09/2019
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Provider Practice Location Address
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Address Line | 14377 WOODLAKE DR STE 315
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City | TOWN AND COUNTRY
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State | MO
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Zip | 63017-5735
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Country | US
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Telephone | 314-304-3707
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Fax |
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Provider Business Mailing Address
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Address Line | 14377 WOODLAKE DR STE 315
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City | TOWN AND COUNTRY
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State | MO
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Zip | 63017-5735
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Country | US
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Telephone | 314-304-3707
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2002021877
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License Number State | MO
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