Provider Demographics
NPI:1841324753
Name:VLIETSTRA, ALICE G (PHD)
Entity type:Individual
Prefix:DR
First Name:ALICE
Middle Name:G
Last Name:VLIETSTRA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3042 ANDOVER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4606
Mailing Address - Country:US
Mailing Address - Phone:314-882-5537
Mailing Address - Fax:314-298-9274
Practice Address - Street 1:12131 DORSETT RD
Practice Address - Street 2:SUITE 220
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-2418
Practice Address - Country:US
Practice Address - Phone:314-729-2855
Practice Address - Fax:314-298-9274
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01089103TH0100X
MO300075106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1601OtherBLUE CROSS BLUE SHIELD
MO075243OtherVALUE OPTIONS
MO000070134Medicare ID - Type UnspecifiedPROVIDER #