Provider Demographics
NPI:1972629434
Name:WATSON, STACEY BURRACK (LCPC)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:BURRACK
Last Name:WATSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W GOLF RD STE 16
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3923
Mailing Address - Country:US
Mailing Address - Phone:847-577-0904
Mailing Address - Fax:847-577-1558
Practice Address - Street 1:415 W GOLF RD STE 16
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005
Practice Address - Country:US
Practice Address - Phone:847-577-0904
Practice Address - Fax:847-577-1558
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006108101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635186OtherBCBS