Provider Demographics
NPI:1659359800
Name:ROTH, STACEY ANN (LPC)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ANN
Last Name:ROTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 ASH SPGS
Mailing Address - Street 2:
Mailing Address - City:HOUSE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63051-3654
Mailing Address - Country:US
Mailing Address - Phone:314-971-5797
Mailing Address - Fax:636-323-2250
Practice Address - Street 1:5800 ASH SPGS
Practice Address - Street 2:
Practice Address - City:HOUSE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:63051-3654
Practice Address - Country:US
Practice Address - Phone:314-971-5797
Practice Address - Fax:636-323-2250
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005028635101YM0800X, 171M00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497513705Medicaid