Provider Demographics
NPI:1942801006
Name:DAY, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:DAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3248 VANDEVER AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6274
Mailing Address - Country:US
Mailing Address - Phone:309-347-5522
Mailing Address - Fax:
Practice Address - Street 1:3248 VANDEVER AVE
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6274
Practice Address - Country:US
Practice Address - Phone:309-347-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
34473101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
34473OtherCADC