=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144130451
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY SUSAN IVERSON MT-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2026
-----------------------------------------------------
Last Update Date | 09/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1465 S GRAND BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63104-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-268-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9619 LABETTE DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63123-6622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-809-1207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225A00000X
-----------------------------------------------------
Taxonomy Name | Music Therapist
-----------------------------------------------------
License Number | 15711
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------