Healthcare Provider Details

I. General information

NPI: 1659359800
Provider Name (Legal Business Name): STACEY ANN ROTH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 ASH SPGS
HOUSE SPRINGS MO
63051-3654
US

IV. Provider business mailing address

5800 ASH SPGS
HOUSE SPRINGS MO
63051-3654
US

V. Phone/Fax

Practice location:
  • Phone: 314-971-5797
  • Fax: 636-323-2250
Mailing address:
  • Phone: 314-971-5797
  • Fax: 636-323-2250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2005028635
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number2005028635
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2005028635
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: