Provider Demographics
NPI:1063676427
Name:PELTON, STACEY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:PELTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:PELTON MAX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1920 THOREAU DR N
Mailing Address - Street 2:SUITE 151
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4176
Mailing Address - Country:US
Mailing Address - Phone:847-303-1880
Mailing Address - Fax:847-303-1881
Practice Address - Street 1:1920 THOREAU DR N
Practice Address - Street 2:SUITE 151
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4176
Practice Address - Country:US
Practice Address - Phone:847-303-1880
Practice Address - Fax:847-303-1881
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.005848103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical