Provider Demographics
NPI:1679647820
Name:MEISBURGER, DARYL LYNNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DARYL
Middle Name:LYNNE
Last Name:MEISBURGER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:DARYL
Other - Middle Name:LYNNE
Other - Last Name:MEISBURGER-GREENLUND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:529 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-2903
Mailing Address - Country:US
Mailing Address - Phone:636-283-5047
Mailing Address - Fax:636-283-5049
Practice Address - Street 1:529 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2903
Practice Address - Country:US
Practice Address - Phone:636-283-5047
Practice Address - Fax:636-283-5049
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01619103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO496994708Medicaid
MO000070727Medicare ID - Type Unspecified