MEDICARE: DR. JEFFREY BRENT FARB PSYD.

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	01073	MO

General Provider Information

NPI Number	:	1972520971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY BRENT FARB PSYD.

Provider Business Mailing Address
First Line	:	1035 BELLEVUE AVE STE 105
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1847
Country	:	US
Telephone Number	:	314-645-7411
Fax Number	:	314-645-5678

Provider Business Practice Location Address
First Line	:	1035 BELLEVUE AVE STE 105
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1847
Country	:	US
Telephone Number	:	314-645-7411
Fax Number	:	314-645-5678

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

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

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