Provider Demographics
NPI:1578010211
Name:CAMPBELL, STACIE X (LPC)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:CAMPBELL
Suffix:X
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 1:2924 STANTON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-4315
Mailing Address - Country:US
Mailing Address - Phone:217-585-9185
Mailing Address - Fax:
Practice Address - Street 1:2924 STANTON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4315
Practice Address - Country:US
Practice Address - Phone:217-585-9185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178011722101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional