Provider Demographics
NPI:1588630966
Name:CLOSSON, STACEY J (LMHC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:CLOSSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:J
Other - Last Name:GRASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9058
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:606-328-5153
Practice Address - Street 1:2410 GRAPE RD STE 6
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3015
Practice Address - Country:US
Practice Address - Phone:574-283-1234
Practice Address - Fax:574-537-2652
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000588A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN39000588AOtherLICENSE