Provider Demographics
NPI:1417286006
Name:ACKERMAN, STACI
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3809 W CARDINAL ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-4701
Mailing Address - Country:US
Mailing Address - Phone:417-343-1349
Mailing Address - Fax:
Practice Address - Street 1:1119 S ELLIOTT AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2405
Practice Address - Country:US
Practice Address - Phone:417-671-9856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional