Provider Demographics
NPI:1396827234
Name:CARR-PETERSON, STACIA C
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:C
Last Name:CARR-PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:C
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:560 W CANFIELD AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7950
Mailing Address - Country:US
Mailing Address - Phone:208-758-7111
Mailing Address - Fax:
Practice Address - Street 1:560 W CANFIELD AVE
Practice Address - Street 2:STE 300
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7950
Practice Address - Country:US
Practice Address - Phone:208-758-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3456101YP2500X
VA0701004015101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional