Healthcare Provider Details

I. General information

NPI: 1407635337
Provider Name (Legal Business Name): STACEY ETTIENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2023
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7280 NW 87TH TER STE C-210
KANSAS CITY MO
64153-3720
US

IV. Provider business mailing address

1607 SYLVAN LN
COLUMBIA MO
65202-3607
US

V. Phone/Fax

Practice location:
  • Phone: 855-284-6634
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2026022902
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: