Provider Demographics
NPI:1043408313
Name:LEE, STACY RENEE (LCSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:RENEE
Last Name:LEE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19636
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9636
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-4735
Practice Address - Street 1:751 N RUTLEDGE ST STE 1100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-4735
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490127261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854005Medicaid
IL370966854024Medicaid
IL370966854002Medicaid
IL370966854004Medicaid
IL370966854015Medicaid
ILCF3444OtherMEDICARE RR
IL141016Medicare Oscar/Certification
IL141840Medicare Oscar/Certification
IL141112Medicare Oscar/Certification
IL370966854002Medicaid
IL370966854015Medicaid
IL141849Medicare Oscar/Certification