Healthcare Provider Details

I. General information

NPI: 1366354185
Provider Name (Legal Business Name): STACY CARLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 KENILWORTH LN
BALLWIN MO
63011-2458
US

IV. Provider business mailing address

530 KENILWORTH LN
BALLWIN MO
63011-2458
US

V. Phone/Fax

Practice location:
  • Phone: 314-297-7721
  • Fax:
Mailing address:
  • Phone: 314-297-7721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2012029302
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: