Basic Information
| Provider Information | |||||||||
| NPI: | 1104908599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIESELER | ||||||||
| FirstName: | VICKY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TUPPER | ||||||||
| OtherFirstName: | VICKY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 308 METALWOOD CIR | ||||||||
| Address2: | |||||||||
| City: | CARL JUNCTION | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648349601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176496522 | ||||||||
| FaxNumber: | 4134377729 | ||||||||
| Practice Location | |||||||||
| Address1: | 2808 S PICHER AVE | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477700 | ||||||||
| FaxNumber: | 4173477729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 01596 | MO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.