Healthcare Provider Details

I. General information

NPI: 1053766063
Provider Name (Legal Business Name): STACEY D MIDDLETON MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY YOUNG

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 OLD SOUTH RIVER RD
ST. CHARLES MO
63303
US

IV. Provider business mailing address

2885 W BATTLEFIELD ST
SPRINGFIELD MO
65807-3952
US

V. Phone/Fax

Practice location:
  • Phone: 636-224-1029
  • Fax:
Mailing address:
  • Phone: 417-761-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2015000499
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: