Provider Demographics
NPI:1861716417
Name:VAN ISEGHEM, THERESA M (PSYD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:M
Last Name:VAN ISEGHEM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 POINTE LOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-4301
Mailing Address - Country:US
Mailing Address - Phone:314-591-0093
Mailing Address - Fax:
Practice Address - Street 1:2727 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1421
Practice Address - Country:US
Practice Address - Phone:314-534-8778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007872103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical