MEDICARE: D. EARLY, PH.D., INC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	2006028096	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1649347329	OTHER	MO	NPIN AS AN INDIVIDUAL PROVIDER
2	11798822	OTHER	MO	CAQH

General Provider Information

NPI Number	:	1306142278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	D. EARLY, PH.D., INC.

Provider Business Mailing Address
First Line	:	6220 S LINDBERGH BLVD
Second Line	:	SUITE 300
City	:	SAINT LOUIS
State	:	MO
Zip	:	63123-7839
Country	:	US
Telephone Number	:	314-894-2900
Fax Number	:	314-894-2960

Provider Business Practice Location Address
First Line	:	6220 S LINDBERGH BLVD
Second Line	:	SUITE 300
City	:	SAINT LOUIS
State	:	MO
Zip	:	63123-7839
Country	:	US
Telephone Number	:	314-894-2900
Fax Number	:	314-894-2960

Authorized Official
Title or Position	:	PRESIDENT, LICENSED PSYCHOLOGIST
Name	:	DR. DEBRA J EARLY
Credential	:	PH.D.
Telephone Number	:	314-894-2900

Provider Enumeration Date	:	02/09/2011
Last Update Date	:	02/09/2011

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