Provider Demographics
NPI:1609180579
Name:HOUSE, STACY JO (MED, NCC)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:JO
Last Name:HOUSE
Suffix:
Gender:F
Credentials:MED, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 S.E. ASCENSION COMPLEX
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737
Mailing Address - Country:US
Mailing Address - Phone:225-621-1116
Mailing Address - Fax:225-644-3208
Practice Address - Street 1:1112 S.E. ASCENSION COMPLEX AVENUE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737
Practice Address - Country:US
Practice Address - Phone:225-621-1116
Practice Address - Fax:225-644-3208
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACI 4621101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health