Provider Demographics
NPI:1558473751
Name:PETREY, STEPHANIE (LCPC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PETREY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MAINOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:159 S CHARLOTTE ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-2659
Mailing Address - Country:US
Mailing Address - Phone:708-373-0113
Mailing Address - Fax:
Practice Address - Street 1:1010 JORIE BLVD
Practice Address - Street 2:STE 112
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2215
Practice Address - Country:US
Practice Address - Phone:708-373-0113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178-003635101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional