Provider Demographics
NPI:1093034415
Name:CARR, STACIE LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:CARR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:LYNN
Other - Last Name:TALBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1304 PLUM AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2532
Mailing Address - Country:US
Mailing Address - Phone:618-335-7364
Mailing Address - Fax:
Practice Address - Street 1:1304 PLUM AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2532
Practice Address - Country:US
Practice Address - Phone:618-335-7364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0141201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical