Provider Demographics
NPI:1225781115
Name:EDERER, STACEY LYNN
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LYNN
Last Name:EDERER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:COCHRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:6617 E YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-1521
Mailing Address - Country:US
Mailing Address - Phone:314-402-4677
Mailing Address - Fax:
Practice Address - Street 1:6617 E YORKSHIRE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-1521
Practice Address - Country:US
Practice Address - Phone:314-402-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010028186104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker