Healthcare Provider Details

I. General information

NPI: 1841531548
Provider Name (Legal Business Name): MICHAEL ROLAND LEVEQUE PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 11/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S TAYLOR AVE DEPT PSYCHIATRY, STE 122
SAINT LOUIS MO
63110-1035
US

IV. Provider business mailing address

600 S TAYLOR AVE DEPT PSYCHIATRY, STE 122
SAINT LOUIS MO
63110-1035
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-1700
  • Fax: 314-362-7017
Mailing address:
  • Phone: 314-286-1700
  • Fax: 314-362-7017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2012001790
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: