Provider Demographics
NPI:1598845943
Name:TISHEY, LAURA R (PSYD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:R
Last Name:TISHEY
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 1:932 ALANSON DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-5004
Mailing Address - Country:US
Mailing Address - Phone:636-248-0568
Mailing Address - Fax:
Practice Address - Street 1:655 CRAIG RD STE 230
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7170
Practice Address - Country:US
Practice Address - Phone:636-248-0568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006006569103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490684206Medicaid
MO221811347Medicare PIN