MEDICARE: DR. JOHN KURIAKO THEKKEDAM 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	103TC0700X	Clinical Psychologist	01242	MO
2	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1477659498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN KURIAKO THEKKEDAM PH.D.

Provider Business Mailing Address
First Line	:	1505 HAVILAND DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63137-1559
Country	:	US
Telephone Number	:	314-868-2400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1505 HAVILAND DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63137-1559
Country	:	US
Telephone Number	:	314-868-2400
Fax Number	:

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	07/08/2007

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