Provider Demographics
NPI:1992177810
Name:MICELI, KRISTEN (PSYD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:MICELI
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 1:12837 FLUSHING MEADOWS DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1824
Mailing Address - Country:US
Mailing Address - Phone:314-516-5824
Mailing Address - Fax:
Practice Address - Street 1:12837 FLUSHING MEADOWS DR
Practice Address - Street 2:SUITE 220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1824
Practice Address - Country:US
Practice Address - Phone:314-516-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-30
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015037859103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical