MEDICARE: QUANTUM BEHAVIORAL, 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	:	1871255695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUANTUM BEHAVIORAL, LLC

Provider Business Mailing Address
First Line	:	665 S SKINKER BLVD APT 16B
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63105-2353
Country	:	US
Telephone Number	:	314-809-3964
Fax Number	:

Provider Business Practice Location Address
First Line	:	665 S SKINKER BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63105-2313
Country	:	US
Telephone Number	:	314-809-3964
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	LAWRENCE E SHAPIRO
Credential	:	PHD
Telephone Number	:	314-809-3964

Provider Enumeration Date	:	10/08/2021
Last Update Date	:	10/11/2021

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