Provider Demographics
NPI:1588039663
Name:NAGORSKI, STACIE (LPC)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:NAGORSKI
Suffix:
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 1:3160 REVERE RD
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-3631
Mailing Address - Country:US
Mailing Address - Phone:715-570-7267
Mailing Address - Fax:
Practice Address - Street 1:4351 W COLLEGE AVE STE 410
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6468-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10049991Medicaid