Provider Demographics
NPI:1518227032
Name:FORTENBERRY, STACY SIMS (LPC)
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:SIMS
Last Name:FORTENBERRY
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 1:22 BLOSSOM CIR
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-3585
Mailing Address - Country:US
Mailing Address - Phone:601-550-7383
Mailing Address - Fax:
Practice Address - Street 1:5 ORLEANS DR
Practice Address - Street 2:SUITE 2
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8675
Practice Address - Country:US
Practice Address - Phone:601-550-7383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0669101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional