Provider Demographics
NPI:1336941863
Name:FASOLDT, MARY MELISSA (LPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MELISSA
Last Name:FASOLDT
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 S CLAY AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5888
Mailing Address - Country:US
Mailing Address - Phone:314-467-8162
Mailing Address - Fax:
Practice Address - Street 1:404 S CLAY AVE STE 204
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-5888
Practice Address - Country:US
Practice Address - Phone:314-467-8162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025008024101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional