Healthcare Provider Details

I. General information

NPI: 1407682479
Provider Name (Legal Business Name): MELISSA KERN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11358 VAN CLEVE AVE
SAINT LOUIS MO
63114-1131
US

IV. Provider business mailing address

3640 BOSWELL AVE
SAINT LOUIS MO
63114-4026
US

V. Phone/Fax

Practice location:
  • Phone: 314-968-2350
  • Fax:
Mailing address:
  • Phone: 314-368-1128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2024017281
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: