Basic Information
| Provider Information | |||||||||
| NPI: | 1770913089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARLES | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10004 KENNERLY RD | ||||||||
| Address2: | STE 364B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145254429 | ||||||||
| FaxNumber: | 3145257260 | ||||||||
| Practice Location | |||||||||
| Address1: | 10004 KENNERLY RD | ||||||||
| Address2: | STE 364B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145254429 | ||||||||
| FaxNumber: | 3145257260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2013 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | 2013037719 | MO | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 363LP0808X | 2013037719 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1770913089 | 05 | MO | MEDICAID |