Provider Demographics
NPI:1699211490
Name:SIMON, STACEY (MA, LCDP, ICADC, MHS)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:MA, LCDP, ICADC, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30716 CYPRESS LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:DE
Mailing Address - Zip Code:19956-3514
Mailing Address - Country:US
Mailing Address - Phone:302-381-8483
Mailing Address - Fax:
Practice Address - Street 1:505 W MARKET ST
Practice Address - Street 2:SUITE 110
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-2344
Practice Address - Country:US
Practice Address - Phone:302-854-0626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECD-0000082101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)