Provider Demographics
NPI:1548089204
Name:MASSARELLA, ANTHONY (BC- HIS)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:MASSARELLA
Suffix:
Gender:M
Credentials:BC- HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 SULLIVAN POINTE DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-1766
Mailing Address - Country:US
Mailing Address - Phone:314-853-1593
Mailing Address - Fax:
Practice Address - Street 1:3551 VETERANS MEMORIAL PKWY STE 201
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-1123
Practice Address - Country:US
Practice Address - Phone:314-853-1593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021004907237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist