Provider Demographics
NPI:1407998693
Name:STOLL, MARCIA LOUESA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:LOUESA
Last Name:STOLL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2663 FARRAGUT DR
Mailing Address - Street 2:STE A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1462
Mailing Address - Country:US
Mailing Address - Phone:217-726-6300
Mailing Address - Fax:217-679-5987
Practice Address - Street 1:2663 FARRAGUT DR
Practice Address - Street 2:STE A
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1462
Practice Address - Country:US
Practice Address - Phone:217-726-6300
Practice Address - Fax:217-679-5987
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490032591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00084321111OtherBLUECROSSBLUESHIELD PIN
IL107001OtherHEALTH ALLIANCE PIN
IL228367000OtherMAGELLAN PIN
IL107001OtherHEALTH ALLIANCE PIN