Provider Demographics
NPI:1558359489
Name:STACEY, CHRISTINE F (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:F
Last Name:STACEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 IRONWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1864
Mailing Address - Country:US
Mailing Address - Phone:574-243-9370
Mailing Address - Fax:574-243-9375
Practice Address - Street 1:2106 IRONWOOD CIR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1864
Practice Address - Country:US
Practice Address - Phone:574-243-9370
Practice Address - Fax:574-243-9375
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
34004960A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN255960Medicare UPIN