Healthcare Provider Details

I. General information

NPI: 1114253952
Provider Name (Legal Business Name): MICHELE LEE PERGADIA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE DEPT PSYCHIATRY, STE 441
SAINT LOUIS MO
63108-1495
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-1700
  • Fax: 314-970-9094
Mailing address:
  • Phone: 314-286-1700
  • Fax: 314-970-9094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2006016151
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2006016151
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: