Provider Demographics
NPI:1346544053
Name:STUMBO, LANCE JEREMY (LMFT)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:JEREMY
Last Name:STUMBO
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 DOUGLAS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-5310
Mailing Address - Country:US
Mailing Address - Phone:515-232-2640
Mailing Address - Fax:515-233-2129
Practice Address - Street 1:600 1ST AVE
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:IA
Practice Address - Zip Code:50220-1803
Practice Address - Country:US
Practice Address - Phone:515-232-2640
Practice Address - Fax:515-233-2129
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000329101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health