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General NPI Number Information
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NPI Number | 1841324753
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Entity Type | Individual
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Provider Name | ALICE G VLIETSTRA PH.D.
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Gender | Female
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Dates
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Enumeration Date | 03/15/2007
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Last Update Date | 10/27/2025
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Provider Practice Location Address
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Address Line | 745 CRAIG RD STE 102C
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City | SAINT LOUIS
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State | MO
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Zip | 63141-7122
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Country | US
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Telephone | 314-729-2855
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Fax | 314-529-3534
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Provider Business Mailing Address
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Address Line | 3042 ANDOVER DR
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City | SAINT LOUIS
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State | MO
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Zip | 63121-4606
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Country | US
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Telephone | 314-882-5537
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Fax | 314-529-3534
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number | 01089
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 300075
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License Number State | MO
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