Provider Demographics
NPI:1114286358
Name:LUCE, STACY NICOLE (LCPC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:NICOLE
Last Name:LUCE
Suffix:
Gender:F
Credentials:LCPC
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 203
Mailing Address - Street 2:
Mailing Address - City:KOOTENAI
Mailing Address - State:ID
Mailing Address - Zip Code:83840-0203
Mailing Address - Country:US
Mailing Address - Phone:810-845-4472
Mailing Address - Fax:
Practice Address - Street 1:404 KOOTENAI ST
Practice Address - Street 2:
Practice Address - City:KOOTENAI
Practice Address - State:ID
Practice Address - Zip Code:83840-0276
Practice Address - Country:US
Practice Address - Phone:810-845-4472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-6335101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1114286358Medicaid