Provider Demographics
NPI:1821523580
Name:GRAVES, STACEY LYNN (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:GRAVES
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:PO BOX 7874
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-7874
Mailing Address - Country:US
Mailing Address - Phone:406-690-7753
Mailing Address - Fax:
Practice Address - Street 1:913 SW HIGGINS AVE STE 202
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1423
Practice Address - Country:US
Practice Address - Phone:406-690-7753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-18899101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional