Provider Demographics
NPI:1710224936
Name:MUNOZ, STACEY JO (MA, LCPC)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:JO
Last Name:MUNOZ
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6707 N SHERIDAN RD STE N
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2848
Mailing Address - Country:US
Mailing Address - Phone:309-453-3604
Mailing Address - Fax:309-453-3604
Practice Address - Street 1:6707 N SHERIDAN RD STE N
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2848
Practice Address - Country:US
Practice Address - Phone:309-453-3604
Practice Address - Fax:309-453-3604
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007832101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional