Provider Demographics
NPI:1366762577
Name:ANTHONY UDZIELA PHD LLC
Entity type:Organization
Organization Name:ANTHONY UDZIELA PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:UDZIELA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:314-614-9730
Mailing Address - Street 1:13354 MANCHESTER ROAD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ST. LOUISL
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-614-9730
Mailing Address - Fax:314-692-7929
Practice Address - Street 1:13354 MANCHESTER ROAD
Practice Address - Street 2:SUITE 220
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1739
Practice Address - Country:US
Practice Address - Phone:314-614-9730
Practice Address - Fax:314-692-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty