Provider Demographics
NPI:1326614421
Name:BLAND, STACY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BLAND
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1109
Mailing Address - Country:US
Mailing Address - Phone:815-303-1954
Mailing Address - Fax:
Practice Address - Street 1:917 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1109
Practice Address - Country:US
Practice Address - Phone:815-303-1954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490132291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149013229OtherLICENSED CLINICAL SOCIAL WORKER