MEDICARE: IESHA JOSEPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TH0100X	Health Service Psychologist		MO

General Provider Information

NPI Number	:	1073045340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IESHA JOSEPH

Provider Business Mailing Address
First Line	:	7251 OLIVE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63130-2322
Country	:	US
Telephone Number	:	314-749-7618
Fax Number	:	314-862-6155

Provider Business Practice Location Address
First Line	:	7251 OLIVE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63130-2322
Country	:	US
Telephone Number	:	314-749-7618
Fax Number	:	314-862-6155

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	03/28/2017

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Directions to “ IESHA JOSEPH ” Practice Location

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