NPI |
1932186129 |
The first name of the provider, if the provider
is an individual. |
Entity Type Code |
1 |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Last Name Legal Name |
SCOTT |
The middle name of the provider, if the provider
is an individual. |
Provider First Name |
STACY |
The first name of the provider, if the provider
is an individual. |
Provider Middle Name |
J |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Credential Text |
LCSW |
The country code in the location address of the provider being identified. |
Provider First Line Business Practice Location Address |
760 PLANTATION BLVD |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
SIKESTON |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address State Name |
MO |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
638015736 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
5734710800 |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Fax Number |
5734710810 |
The fax number associated with the location
address of the provider being identified. |
Provider Enumeration Date |
12/28/2005 |
|
Last Update Date |
9/24/2008 |
The date that a record was last updated or changed. |
Provider Gender Code |
F |
The first name of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
1041C0700X |
The title or position of the authorized official. |
Provider License Number 1 |
2002014995 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider License Number State Code 1 |
MO |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Other Provider Identifier 1 |
495201014 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Other Provider Identifier Type Code 1 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Other Provider Identifier State 1 |
MO |
|
Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |