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NPI Code Detail

MEDICARE: MICHAEL KOLESSAR PSY.D.

MEDICARE: MICHAEL KOLESSAR PSY.D.
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
1103G00000XClinical Neuropsychologist

General Provider Information

NPI Number : 1134458201
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHAEL KOLESSAR PSY.D.
Provider Business Mailing Address
First Line : 12380 DE PAUL DR
Second Line :
City : BRIDGETON
State : MO
Zip : 63044-2511
Country : US
Telephone Number : 314-447-9705
Fax Number :
Provider Business Practice Location Address
First Line : 12380 DE PAUL DR
Second Line :
City : BRIDGETON
State : MO
Zip : 63044-2511
Country : US
Telephone Number : 314-447-9705
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/18/2009
Last Update Date : 10/03/2013

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