Healthcare Provider Details

I. General information

NPI: 1184613218
Provider Name (Legal Business Name): CLA H. STEARNS II PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 KROHN DR
BOONVILLE MO
65233-1853
US

IV. Provider business mailing address

1104 KROHN DR
BOONVILLE MO
65233-1853
US

V. Phone/Fax

Practice location:
  • Phone: 660-882-8149
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2001014364
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: