Provider Demographics
NPI:1184402489
Name:STAGEBERG, AMY (SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:STAGEBERG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5105
Mailing Address - Country:US
Mailing Address - Phone:573-339-1201
Mailing Address - Fax:
Practice Address - Street 1:301 CLARK AVE
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5105
Practice Address - Country:US
Practice Address - Phone:573-339-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002021124235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist