Provider Demographics
NPI:1821066242
Name:VAN PELT, DAVID MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:VAN PELT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 S KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-4415
Mailing Address - Country:US
Mailing Address - Phone:573-472-2139
Mailing Address - Fax:573-472-6457
Practice Address - Street 1:903 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4415
Practice Address - Country:US
Practice Address - Phone:573-472-2139
Practice Address - Fax:573-472-6457
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO2005015544103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOSDA3992113OtherCHILD TREATMENT SERVICES
MO499322014Medicaid
MO499322014Medicaid