Provider Demographics
NPI:1497071278
Name:SALEM, STACY JOLYNN (LPC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JOLYNN
Last Name:SALEM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 US HIGHWAY 50 BYP
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2230
Mailing Address - Country:US
Mailing Address - Phone:620-227-8566
Mailing Address - Fax:620-225-8566
Practice Address - Street 1:2101 US HIGHWAY 50 BYP
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2230
Practice Address - Country:US
Practice Address - Phone:620-227-8566
Practice Address - Fax:620-225-8566
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional