MEDICARE: ANTHONY UDZIELA PHD LLC

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1366762577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTHONY UDZIELA PHD LLC

Provider Business Mailing Address
First Line	:	13354 MANCHESTER ROAD
Second Line	:	SUITE 220
City	:	ST. LOUISL
State	:	MO
Zip	:	63131
Country	:	US
Telephone Number	:	314-614-9730
Fax Number	:	314-692-7929

Provider Business Practice Location Address
First Line	:	13354 MANCHESTER ROAD
Second Line	:	SUITE 220
City	:	ST. LOUIS
State	:	MO
Zip	:	63131-1739
Country	:	US
Telephone Number	:	314-614-9730
Fax Number	:	314-692-7929

Authorized Official
Title or Position	:	OWNER
Name	:	ANTHONY DALE UDZIELA
Credential	:	PHD
Telephone Number	:	314-614-9730

Provider Enumeration Date	:	06/10/2010
Last Update Date	:	07/11/2010

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