Provider Demographics
NPI:1063853877
Name:COTTRELL, STACIE ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:ELLEN
Last Name:COTTRELL
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 1:985 E 4500 S
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4153
Mailing Address - Country:US
Mailing Address - Phone:385-881-3398
Mailing Address - Fax:
Practice Address - Street 1:985 E 4500 S
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84117-4153
Practice Address - Country:US
Practice Address - Phone:385-881-3398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10875612-35011041S0200X, 1041C0700X
167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician