Healthcare Provider Details

I. General information

NPI: 1245166479
Provider Name (Legal Business Name): STACI ARCHIBALD M.S., PLBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 SOCCER PARK RD
FENTON MO
63026-2564
US

IV. Provider business mailing address

312 COUNTRYSHIRE DR
LAKE SAINT LOUIS MO
63367-5820
US

V. Phone/Fax

Practice location:
  • Phone: 636-485-5556
  • Fax:
Mailing address:
  • Phone: 636-485-5556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberE173177007
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: