Provider Demographics
NPI:1003996331
Name:SOLTYSIAK, KIM ANN (LPC)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:ANN
Last Name:SOLTYSIAK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 CLAYTON RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1328
Mailing Address - Country:US
Mailing Address - Phone:314-960-0632
Mailing Address - Fax:618-281-8127
Practice Address - Street 1:2637 KORY DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2654
Practice Address - Country:US
Practice Address - Phone:314-960-0632
Practice Address - Fax:618-281-8127
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11463170OtherCAQH