Provider Demographics
NPI:1467662965
Name:BURTON, STACEY A
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:BURTON
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 1:518 N HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-1323
Mailing Address - Country:US
Mailing Address - Phone:417-732-3609
Mailing Address - Fax:417-732-3605
Practice Address - Street 1:REPUBLIC R-III
Practice Address - Street 2:518 N HAMPTON AVE
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1323
Practice Address - Country:US
Practice Address - Phone:417-732-3609
Practice Address - Fax:417-732-3605
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118464235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO465697613Medicaid