Provider Demographics
NPI:1912923897
Name:STATLER, JUDY K (LPC)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:K
Last Name:STATLER
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 1:724 JACKSON TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-2616
Mailing Address - Country:US
Mailing Address - Phone:573-243-3482
Mailing Address - Fax:
Practice Address - Street 1:115 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-7326
Practice Address - Country:US
Practice Address - Phone:573-334-0018
Practice Address - Fax:573-334-0984
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001181101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11349681OtherCAQH
MOA309278OtherVALUE OPTIONS
MO188959OtherANTHEM BLUECROSSBLUESHIEL
MO656053OtherHEALTHLINK