Healthcare Provider Details

I. General information

NPI: 1841324753
Provider Name (Legal Business Name): ALICE G VLIETSTRA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 CRAIG RD STE 102C
SAINT LOUIS MO
63141-7122
US

IV. Provider business mailing address

3042 ANDOVER DR
SAINT LOUIS MO
63121-4606
US

V. Phone/Fax

Practice location:
  • Phone: 314-729-2855
  • Fax: 314-529-3534
Mailing address:
  • Phone: 314-882-5537
  • Fax: 314-529-3534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number01089
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number300075
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: