Healthcare Provider Details

I. General information

NPI: 1982904785
Provider Name (Legal Business Name): STACIE F BUNNING PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HUBER PARK CT SUITE 109
WELDON SPRING MO
63304-8683
US

IV. Provider business mailing address

500 HUBER PARK CT SUITE 109
WELDON SPRING MO
63304-8683
US

V. Phone/Fax

Practice location:
  • Phone: 314-363-7557
  • Fax:
Mailing address:
  • Phone: 314-363-7557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number01738
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: