Provider Demographics
NPI:1841612561
Name:SEELY, ERICA (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:SEELY
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N 4TH ST
Mailing Address - Street 2:APT 2306
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63102-1908
Mailing Address - Country:US
Mailing Address - Phone:618-713-2106
Mailing Address - Fax:
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:314-344-7961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013041783133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered