Provider Demographics
NPI:1104908599
Name:MIESELER, VICKY LYNN (MS)
Entity type:Individual
Prefix:MRS
First Name:VICKY
Middle Name:LYNN
Last Name:MIESELER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:VICKY
Other - Middle Name:LYNN
Other - Last Name:TUPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:308 METALWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:CARL JUNCTION
Mailing Address - State:MO
Mailing Address - Zip Code:64834-9601
Mailing Address - Country:US
Mailing Address - Phone:417-649-6522
Mailing Address - Fax:413-437-7729
Practice Address - Street 1:2808 S PICHER AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1645
Practice Address - Country:US
Practice Address - Phone:417-347-7700
Practice Address - Fax:417-347-7729
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01596103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical