Healthcare Provider Details

I. General information

NPI: 1770820037
Provider Name (Legal Business Name): LISA L KRYSTOSEK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8135 MANCHESTER RD
SAINT LOUIS MO
63144-2821
US

IV. Provider business mailing address

925 WESTMINSTER ABBY LN APT 301
FENTON MO
63026-7708
US

V. Phone/Fax

Practice location:
  • Phone: 314-779-4550
  • Fax:
Mailing address:
  • Phone: 314-779-4550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2012037167
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: