Provider Demographics
NPI:1982904785
Name:BUNNING, STACIE F (PSYD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:F
Last Name:BUNNING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 HUBER PARK CT
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-8683
Mailing Address - Country:US
Mailing Address - Phone:314-363-7557
Mailing Address - Fax:
Practice Address - Street 1:500 HUBER PARK CT
Practice Address - Street 2:SUITE 109
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-8683
Practice Address - Country:US
Practice Address - Phone:314-363-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical