Healthcare Provider Details

I. General information

NPI: 1841667029
Provider Name (Legal Business Name): KAYLIE THOMAS ALLEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 MACKLIND AVE
SAINT LOUIS MO
63110
US

IV. Provider business mailing address

525 CLARA AVE APT 202
SAINT LOUIS MO
63112-1925
US

V. Phone/Fax

Practice location:
  • Phone: 314-534-0200
  • Fax:
Mailing address:
  • Phone: 847-977-6788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number630106367
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: