Provider Demographics
NPI:1780924332
Name:KINSELLA, EILEEN D (LMT, NCBTMB)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:D
Last Name:KINSELLA
Suffix:
Gender:F
Credentials:LMT, NCBTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6816 SCANLAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2539
Mailing Address - Country:US
Mailing Address - Phone:314-608-3862
Mailing Address - Fax:
Practice Address - Street 1:6816 SCANLAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-2539
Practice Address - Country:US
Practice Address - Phone:314-608-3862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001027022174400000X
MO004180-00174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist