Provider Demographics
NPI:1356313704
Name:TODT-STOCKMAN, LAURA S (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:S
Last Name:TODT-STOCKMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 WATSON RD
Mailing Address - Street 2:SUITE G101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-1528
Mailing Address - Country:US
Mailing Address - Phone:636-391-9966
Mailing Address - Fax:636-394-4678
Practice Address - Street 1:498 WOODS MILL RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MO
Practice Address - Zip Code:63011-4144
Practice Address - Country:US
Practice Address - Phone:636-391-9966
Practice Address - Fax:636-394-4678
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001674091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11333680OtherCAQH
MO165469OtherBLUE CROSS
MO486830OtherHEALTHLINK