=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093024044
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICE LUTEN KARANDJEFF PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2010
-----------------------------------------------------
Last Update Date | 07/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7750 CLAYTON RD STE 210
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63117-1342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-440-4165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7750 CLAYTON RD STE 210
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63117-1342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-440-4165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 2010030792
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------