Healthcare Provider Details

I. General information

NPI: 1205779303
Provider Name (Legal Business Name): MICKEE LEA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 EDGEWOOD ST
PARK HILLS MO
63601-2043
US

IV. Provider business mailing address

311 EDGEWOOD ST
PARK HILLS MO
63601-2043
US

V. Phone/Fax

Practice location:
  • Phone: 573-747-6721
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2023050828
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: