Provider Demographics
NPI:1144774647
Name:VERSICAL, CAROLYN ASHLEY MYLES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:ASHLEY MYLES
Last Name:VERSICAL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:CAROLYN
Other - Middle Name:ASHLEY
Other - Last Name:MYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:26 GODWIN LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1542
Mailing Address - Country:US
Mailing Address - Phone:314-971-0900
Mailing Address - Fax:
Practice Address - Street 1:26 GODWIN LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124
Practice Address - Country:US
Practice Address - Phone:314-971-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009714103TC0700X
MO2019018304103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical