Basic Information
Provider Information | |||||||||
NPI: | 1972590537 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GLOVER | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYCHOLOGIST | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 505164 | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631505164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4178294620 | ||||||||
FaxNumber: | 4178294316 | ||||||||
Practice Location | |||||||||
Address1: | 2115 S FREMONT AVE | ||||||||
Address2: | SUITE 3000 | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658042239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4178207708 | ||||||||
FaxNumber: | 4178207951 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2005 | ||||||||
LastUpdateDate: | 09/11/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 01548 | MO | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 680007342 | 01 | MO | RR MEDICARE | OTHER | 183800719 | 05 | AR |   | MEDICAID | 493583108 | 05 | MO |   | MEDICAID | 1972590537 | 05 | MO |   | MEDICAID | 200286220A | 05 | OK |   | MEDICAID | P00251264 | 01 |   | RR MEDICARE | OTHER | P00894315 | 01 | AR | RR MEDICARE | OTHER | 493583124 | 05 | MO |   | MEDICAID |