Provider Demographics
NPI:1942742754
Name:SEIBOLD, STACEY (LCSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SEIBOLD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 W WASHINGTON BLVD # 251
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2203
Mailing Address - Country:US
Mailing Address - Phone:847-496-3876
Mailing Address - Fax:
Practice Address - Street 1:1137 W MONROE ST
Practice Address - Street 2:UNIT 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607
Practice Address - Country:US
Practice Address - Phone:847-496-3876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0201411041C0700X
IL150.101754101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150.101754OtherLSW
IL149.020141OtherLCSW