Provider Demographics
NPI:1801162474
Name:IVESTER, MARSHA J
Entity type:Individual
Prefix:MRS
First Name:MARSHA
Middle Name:J
Last Name:IVESTER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARSHA
Other - Middle Name:J
Other - Last Name:MILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRADC
Mailing Address - Street 1:4218 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63107-1806
Mailing Address - Country:US
Mailing Address - Phone:313-534-6624
Mailing Address - Fax:314-535-4394
Practice Address - Street 1:4218 NORTH GRAND BLVD
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63107-1952
Practice Address - Country:US
Practice Address - Phone:314-534-6624
Practice Address - Fax:314-535-4394
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO16090101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator