Provider Demographics
NPI:1528003258
Name:RISTVEDT, STEPHEN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:L
Last Name:RISTVEDT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8054
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:800-862-9980
Mailing Address - Fax:314-362-1185
Practice Address - Street 1:3015 N BALLAS RD
Practice Address - Street 2:DIV ANES PAIN MGT
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2329
Practice Address - Country:US
Practice Address - Phone:314-996-7200
Practice Address - Fax:314-362-1185
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0283103T00000X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493726103Medicaid
MO000070491Medicare PIN
MO680004402Medicare PIN