Provider Demographics
NPI:1679034516
Name:PERKO, STACEY (MSW, LCSW, SUDC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:PERKO
Suffix:
Gender:F
Credentials:MSW, LCSW, SUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 W EAGLE HILL CIR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-3989
Mailing Address - Country:US
Mailing Address - Phone:801-842-8062
Mailing Address - Fax:
Practice Address - Street 1:3507 N UNIVERSITY AVE STE 350
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6602
Practice Address - Country:US
Practice Address - Phone:801-842-8062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6086382-6005101YA0400X
UT6086382-3501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty