Provider Demographics
NPI:1558020354
Name:GRANT, STACY (LPC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GRANT
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 1:201 S LAKELINE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2719
Mailing Address - Country:US
Mailing Address - Phone:512-843-3852
Mailing Address - Fax:
Practice Address - Street 1:201 S LAKELINE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2719
Practice Address - Country:US
Practice Address - Phone:512-843-3852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60926101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional