Provider Demographics
NPI:1114253952
Name:PERGADIA, MICHELE LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:LEE
Last Name:PERGADIA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-286-1700
Mailing Address - Fax:314-970-9094
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:DEPT PSYCHIATRY, STE 441
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-286-1700
Practice Address - Fax:314-970-9094
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006016151103K00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497158907Medicaid