Provider Demographics
NPI:1508392622
Name:THOME, STACEY MAE KUBISIAK (MS, LPC-IT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MAE KUBISIAK
Last Name:THOME
Suffix:
Gender:F
Credentials:MS, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 8TH ST S STE 101
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-6511
Mailing Address - Country:US
Mailing Address - Phone:715-423-2030
Mailing Address - Fax:
Practice Address - Street 1:3930 8TH ST S STE 101
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-6511
Practice Address - Country:US
Practice Address - Phone:715-423-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3370-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional