=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013286509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STARLA BROOKE WALTON M.S., LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2011
-----------------------------------------------------
Last Update Date | 10/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 N JEFFERSON AVE STE C
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65536-2798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-616-3315
-----------------------------------------------------
Fax | 417-512-7047
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2947 W MOUNT VERNON ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65802-5125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-365-6031
-----------------------------------------------------
Fax | 417-512-7047
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2011026152
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------