Provider Demographics
NPI:1194448605
Name:STUTSMAN, AUDREY (PSYD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:
Last Name:STUTSMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:OLIVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:425 S WOODS MILL RD STE 150
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63017-9528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 S WOODS MILL RD STE 150
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-9528
Practice Address - Country:US
Practice Address - Phone:314-269-0335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2202033767103T00000X, 103TC0700X
MO2022033767103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist