NPIMap

Organization Active NPI

Meditelecare of Missouri LLC

  • Clinical Psychologist
  • Saint Louis, MO
National Provider Identifier
1013416585
Registry record updated May 5, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
Legal business name
MEDITELECARE OF MISSOURI LLC
Practice address
5661 Telegraph Rd Ste 4B
Saint Louis, MO 63129-4275
Phone
(860) 788-6404
NPI assigned
Feb 9, 2018
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 5, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Andrea Godfrey
Title
Credentialing & Enrollment Manager
Phone
(860) 398-6441

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X Primary
Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 104100000X
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X
Geriatric Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0805X
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X

Addresses

Primary practice location

5661 Telegraph Rd Ste 4B
Saint Louis, MO 63129-4275

Mailing address

PO Box 1595
Middletown, CT 06457-8095
Phone (860) 788-6404

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180320001055 MO Part B Supplier - Clinic/Group Practice 2961764584 Receives reassigned benefits from 11 practitioners
Practice locations: Maryville, MO; Oregon, MO; Stanberry, MO; Trenton, MO

National Provider Directory

National Provider Directory

Locations

22371 State Highway 46
#1
Maryville, MO 64468

501 S Monroe St
#2
Oregon, MO 64473

120 S Central Ave
Saint Louis, MO 63105
Phone (314) 201-6459

1311 E 28th St
#4
Trenton, MO 64683

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1518134400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746403200000",
    "number": "1013416585",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1595",
            "city": "MIDDLETOWN",
            "state": "CT",
            "postal_code": "064578095",
            "telephone_number": "860-788-6404",
            "fax_number": "860-829-0495"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5661 TELEGRAPH RD STE 4B",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631294275",
            "telephone_number": "860-788-6404"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDITELECARE OF MISSOURI LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-02-09",
        "last_updated": "2025-05-05",
        "certification_date": "2025-05-05",
        "status": "A",
        "authorized_official_last_name": "GODFREY",
        "authorized_official_first_name": "ANDREA",
        "authorized_official_title_or_position": "CREDENTIALING & ENROLLMENT MANAGER",
        "authorized_official_telephone_number": "860-398-6441"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "104100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0805X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Geriatric Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Louis, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 5, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.