Healthcare Provider Details

I. General information

NPI: 1184694671
Provider Name (Legal Business Name): STEFANI POELKER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OSAGE EXECUTIVE CIR
HOUSE SPRINGS MO
63051-1382
US

IV. Provider business mailing address

100 OSAGE EXECUTIVE CIR
HOUSE SPRINGS MO
63051-1382
US

V. Phone/Fax

Practice location:
  • Phone: 636-677-9977
  • Fax: 636-677-9179
Mailing address:
  • Phone: 636-677-9977
  • Fax: 636-677-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2004000868
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: