Healthcare Provider Details

I. General information

NPI: 1861751919
Provider Name (Legal Business Name): AMANDA CHRISTINE KRACEN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL MS #90-35-703
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

4921 PARKVIEW PL MS #90-35-703
SAINT LOUIS MO
63110-1032
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-8633
  • Fax: 314-362-1904
Mailing address:
  • Phone: 314-454-8633
  • Fax: 314-362-1904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2011035798
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: