Provider Demographics
NPI:1063260719
Name:MURTAUGH, MATTHEW J (PROFESSIONAL COUNSEL)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:MURTAUGH
Suffix:
Gender:M
Credentials:PROFESSIONAL COUNSEL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 S GRAND BLVD APT 308
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1645
Mailing Address - Country:US
Mailing Address - Phone:314-374-0811
Mailing Address - Fax:
Practice Address - Street 1:2211 S GRAND BLVD APT 308
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1645
Practice Address - Country:US
Practice Address - Phone:314-374-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021042218101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional