Provider Demographics
NPI:1285868125
Name:PRAY, STACY JO (LCPC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JO
Last Name:PRAY
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 1:5167 W YARROW RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-9028
Mailing Address - Country:US
Mailing Address - Phone:208-709-0111
Mailing Address - Fax:
Practice Address - Street 1:1448 E CENTER ST STE A1
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4132
Practice Address - Country:US
Practice Address - Phone:208-478-4642
Practice Address - Fax:207-232-8001
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4180101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID4180OtherIDAHO BOARD OF PROFESSIONAL COUNSELING