MEDICARE: DR. MATTHEW DOUGLAS KLIETHERMES PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	2004024732	MO

General Provider Information

NPI Number	:	1255489902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW DOUGLAS KLIETHERMES PH.D.

Provider Business Mailing Address
First Line	:	12112 JEANNETTE MARY DR
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043-4221
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 UNIVERSITY BLVD
Second Line	:	WEINMAN BLDG-UPPER LEVEL
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-4400
Country	:	US
Telephone Number	:	314-516-7231
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/08/2007

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