Provider Demographics
NPI:1558646323
Name:MCCANN, STACY M (LCSW, BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:M
Last Name:MCCANN
Suffix:
Gender:F
Credentials:LCSW, BCBA, LBA
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:M
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1324 TROY RD STE G
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2366
Mailing Address - Country:US
Mailing Address - Phone:586-713-8696
Mailing Address - Fax:
Practice Address - Street 1:1324 TROY RD STE G
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2366
Practice Address - Country:US
Practice Address - Phone:586-713-8696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013042874103K00000X
MO20130337341041C0700X
IL1490245211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst