Provider Demographics
NPI:1750639464
Name:STACEY, TIMOTHY R (LPC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:STACEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:STACEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-472-4357
Mailing Address - Fax:512-703-1394
Practice Address - Street 1:1631 E 2ND ST STE D
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4491
Practice Address - Country:US
Practice Address - Phone:512-804-3600
Practice Address - Fax:512-476-1469
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65902101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional