Provider Demographics
NPI:1558784942
Name:STACY, DEANNA L (MA, LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:L
Last Name:STACY
Suffix:
Gender:F
Credentials:MA, LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15941 HARLEM AVE # 140
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-1609
Mailing Address - Country:US
Mailing Address - Phone:779-435-4271
Mailing Address - Fax:
Practice Address - Street 1:15941 HARLEM AVE # 140
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1609
Practice Address - Country:US
Practice Address - Phone:779-435-4271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180009845101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6029Medicaid