Provider Demographics
NPI:1538470018
Name:LE FEVRE, STACEY RENE (PSYD)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:RENE
Last Name:LE FEVRE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:RENE
Other - Last Name:LE FEVRE YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-3245
Mailing Address - Country:US
Mailing Address - Phone:574-647-1840
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL
Practice Address - Street 2:STE 5570
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1169
Practice Address - Country:US
Practice Address - Phone:574-647-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043223A103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300021361Medicaid
IN259900018OtherMEDICARE PTAN