Provider Demographics
NPI:1598845943
Name:TISHEY, LAURA R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:R
Last Name:TISHEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5351 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5351 DELMAR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-3146
Practice Address - Country:US
Practice Address - Phone:314-877-0589
Practice Address - Fax:314-877-0575
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006006569103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490684206Medicaid
MO221811347Medicare PIN