Provider Demographics
NPI:1891230827
Name:OSWALD, STACEY KATHLEEN (LLPC)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:KATHLEEN
Last Name:OSWALD
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 NORTHLAWN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3866
Mailing Address - Country:US
Mailing Address - Phone:616-490-6471
Mailing Address - Fax:
Practice Address - Street 1:1240 NORTHLAWN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3866
Practice Address - Country:US
Practice Address - Phone:616-490-6471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015581101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor