MEDICARE: PSYCHOLOGICAL SERVICES OF ST. LOUIS, 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	2010030791	MO

General Provider Information

NPI Number	:	1841743317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOLOGICAL SERVICES OF ST. LOUIS, LLC

Provider Business Mailing Address
First Line	:	7110 OAKLAND AVE
Second Line	:	SUITE 105
City	:	RICHMOND HEIGHTS
State	:	MO
Zip	:	63117-1868
Country	:	US
Telephone Number	:	314-884-0779
Fax Number	:	314-227-9327

Provider Business Practice Location Address
First Line	:	7110 OAKLAND AVE
Second Line	:	SUITE 105
City	:	RICHMOND HEIGHTS
State	:	MO
Zip	:	63117-1868
Country	:	US
Telephone Number	:	314-884-0779
Fax Number	:	314-227-9327

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DR. GREGORY A GOLDMAN
Credential	:	PH.D.
Telephone Number	:	314-884-8075

Provider Enumeration Date	:	08/01/2016
Last Update Date	:	08/01/2016

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