Provider Demographics
NPI:1336652718
Name:STACIE SEARS LLC
Entity Type:Organization
Organization Name:STACIE SEARS LLC
Other - Org Name:BLACK DOG COUNSELING LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SEARS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:385-240-4505
Mailing Address - Street 1:2126 S YUMA ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1107
Mailing Address - Country:US
Mailing Address - Phone:385-240-4505
Mailing Address - Fax:
Practice Address - Street 1:2319 S FOOTHILL DR STE 180
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-5403
Practice Address - Country:US
Practice Address - Phone:385-240-4505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-08
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
UT5473800-3501251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health