Healthcare Provider Details

I. General information

NPI: 1548951767
Provider Name (Legal Business Name): CAITLIN ELAYNE ADOLPHSEN KISHORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

967 GARDENVIEW OFFICE PKWY
SAINT LOUIS MO
63141-5917
US

IV. Provider business mailing address

7253 WATSON RD
SAINT LOUIS MO
63119-4401
US

V. Phone/Fax

Practice location:
  • Phone: 314-561-9757
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2026012076
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: