MEDICARE: KRISTEN MICELI PSYD

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	103TC0700X	Clinical Psychologist	2015037859	MO

General Provider Information

NPI Number	:	1992177810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN MICELI PSYD

Provider Business Mailing Address
First Line	:	12837 FLUSHING MEADOWS DR
Second Line	:	SUITE 220
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-1824
Country	:	US
Telephone Number	:	314-516-5824
Fax Number	:

Provider Business Practice Location Address
First Line	:	12837 FLUSHING MEADOWS DR
Second Line	:	SUITE 220
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-1824
Country	:	US
Telephone Number	:	314-516-5824
Fax Number	:

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

Provider Enumeration Date	:	10/30/2015
Last Update Date	:	11/02/2015

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