Provider Demographics
NPI:1396822789
Name:CROUCH, STACIE R (MA, LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:R
Last Name:CROUCH
Suffix:
Gender:F
Credentials:MA, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9610 BALSA DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3179
Mailing Address - Country:US
Mailing Address - Phone:318-798-2198
Mailing Address - Fax:
Practice Address - Street 1:1525 STEPHENS AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4705
Practice Address - Country:US
Practice Address - Phone:318-221-6121
Practice Address - Fax:318-222-7879
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2630OtherLPC
LA912OtherLMFT