Provider Demographics
NPI:1336871029
Name:WALSH, STACEY DAWN (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:DAWN
Last Name:WALSH
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 MCCAUSLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1914
Mailing Address - Country:US
Mailing Address - Phone:314-600-8072
Mailing Address - Fax:
Practice Address - Street 1:4304 MCCAUSLAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1914
Practice Address - Country:US
Practice Address - Phone:314-600-8072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015006346101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional