Healthcare Provider Details

I. General information

NPI: 1073871257
Provider Name (Legal Business Name): STAURLA CHANTEL WAUN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10719 BUCKEYE RD
FESTUS MO
63028
US

IV. Provider business mailing address

510 W PINE ST
FARMINGTON MO
63640-1426
US

V. Phone/Fax

Practice location:
  • Phone: 314-297-0793
  • Fax:
Mailing address:
  • Phone: 573-756-2988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberNLC.0108067
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: