Healthcare Provider Details

I. General information

NPI: 1619200490
Provider Name (Legal Business Name): STEPHANIE M WACASER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE M LOCKHART

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1354 E KINGSLEY ST STE A
SPRINGFIELD MO
65804-7225
US

IV. Provider business mailing address

717 E PLACER MILL RD
NIXA MO
65714-7100
US

V. Phone/Fax

Practice location:
  • Phone: 417-245-2944
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149013694
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2015044120
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: