Provider Demographics
NPI:1568732550
Name:POSITIVE FAMILY DYNAMICS,PC
Entity Type:Organization
Organization Name:POSITIVE FAMILY DYNAMICS,PC
Other - Org Name:POSITIVE FAMILY LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:G
Authorized Official - Last Name:VLIETSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:314-729-2855
Mailing Address - Street 1:3042 ANDOVER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4606
Mailing Address - Country:US
Mailing Address - Phone:314-729-2855
Mailing Address - Fax:
Practice Address - Street 1:745 CRAIG ROAD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7122
Practice Address - Country:US
Practice Address - Phone:314-729-2855
Practice Address - Fax:314-529-3534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01089103TH0100X
MO300075106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO075243OtherVALUE OPTIONS
MO1601OtherBLUE DROSS BLUE SHIELD
MO000070134Medicare UPIN