Provider Demographics
NPI:1417317066
Name:STAMBAUGH, TERRY (LCSW)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:STAMBAUGH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 4TH AVE APT 406
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-8155
Mailing Address - Country:US
Mailing Address - Phone:309-292-2033
Mailing Address - Fax:
Practice Address - Street 1:4600 3RD ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6106
Practice Address - Country:US
Practice Address - Phone:309-779-2018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490183091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical