Provider Demographics
NPI:1003925512
Name:MOREAU, STACEY G (MED, LPC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:G
Last Name:MOREAU
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17094 W SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3420
Mailing Address - Country:US
Mailing Address - Phone:225-673-9572
Mailing Address - Fax:
Practice Address - Street 1:1112 E ASCENSION COMPLEX BLVD
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4265
Practice Address - Country:US
Practice Address - Phone:225-621-5775
Practice Address - Fax:225-644-2846
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2012101YM0800X
LA328106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist