Provider Demographics
NPI:1871843813
Name:STACEY BLAUTH, LPC LCADC
Entity Type:Organization
Organization Name:STACEY BLAUTH, LPC LCADC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANCHETTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-971-8989
Mailing Address - Street 1:1131 LAUREL BLVD
Mailing Address - Street 2:
Mailing Address - City:LANOKA HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08734-2903
Mailing Address - Country:US
Mailing Address - Phone:609-971-8989
Mailing Address - Fax:609-242-3207
Practice Address - Street 1:500 MAIN ST BLDG 2
Practice Address - Street 2:
Practice Address - City:LANOKA HARBOR
Practice Address - State:NJ
Practice Address - Zip Code:08734-2228
Practice Address - Country:US
Practice Address - Phone:609-971-8989
Practice Address - Fax:609-242-3207
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHERYL A. BYK, LCSW LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00350900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty