Healthcare Provider Details

I. General information

NPI: 1992914352
Provider Name (Legal Business Name): AMY KATHLEEN LICIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S BRENTWOOD BLVD DIV NEUROLOGY SLEEP MED, STE 600
SAINT LOUIS MO
63144-1320
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1408
  • Fax: 314-747-4342
Mailing address:
  • Phone: 314-362-1408
  • Fax: 314-747-4342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License Number2009014878
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number2009014878
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2009014878
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: