Basic Information
| Provider Information | |||||||||
| NPI: | 1083202683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZUCCHINI | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PLPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIRKLAND | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1147 E WALNUT STREET | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172125179 | ||||||||
| FaxNumber: | 4177615111 | ||||||||
| Practice Location | |||||||||
| Address1: | 1147 E WALNUT STREET | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658064264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172125179 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2021 | ||||||||
| LastUpdateDate: | 10/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 10/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2021005298 | MO | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 2021005298 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.