Provider Demographics
NPI:1073045340
Name:JOSEPH, IESHA
Entity Type:Individual
Prefix:
First Name:IESHA
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7251 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-2322
Mailing Address - Country:US
Mailing Address - Phone:314-749-7618
Mailing Address - Fax:314-862-6155
Practice Address - Street 1:7251 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-2322
Practice Address - Country:US
Practice Address - Phone:314-749-7618
Practice Address - Fax:314-862-6155
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service