Healthcare Provider Details

I. General information

NPI: 1487627568
Provider Name (Legal Business Name): KATHERINE R LICHTENBERG D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE R. EASLEY

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 04/29/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12647 OLIVE BLVD STE 105
CREVE COEUR MO
63141-6345
US

IV. Provider business mailing address

601 NIRK AVE
KIRKWOOD MO
63122-5626
US

V. Phone/Fax

Practice location:
  • Phone: 314-925-1541
  • Fax:
Mailing address:
  • Phone: 314-606-5644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number113041
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number113041
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: