Healthcare Provider Details

I. General information

NPI: 1245886241
Provider Name (Legal Business Name): STACI R WICKERSHAM MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 E EVERGREEN ST
SPRINGFIELD MO
65803-4300
US

IV. Provider business mailing address

1540 E EVERGREEN ST
SPRINGFIELD MO
65803-4300
US

V. Phone/Fax

Practice location:
  • Phone: 417-823-2900
  • Fax: 417-823-2981
Mailing address:
  • Phone: 417-823-2900
  • Fax: 417-823-2981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2019031610
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2023004758
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: