Provider Demographics
NPI:1376917161
Name:WYANT, STACEY (LCSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WYANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:311 E MAIN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-4878
Mailing Address - Country:US
Mailing Address - Phone:309-297-4911
Mailing Address - Fax:309-265-0336
Practice Address - Street 1:311 E MAIN ST
Practice Address - Street 2:SUITE 420
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-4855
Practice Address - Country:US
Practice Address - Phone:563-265-5202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.011158101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health