Provider Demographics
NPI:1003657131
Name:STACEY DE WITT LCPC LLC (STACEY M DE WITT SOLE MBR)
Entity type:Organization
Organization Name:STACEY DE WITT LCPC LLC (STACEY M DE WITT SOLE MBR)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DE WITT
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:406-529-5121
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-0134
Mailing Address - Country:US
Mailing Address - Phone:406-529-5121
Mailing Address - Fax:
Practice Address - Street 1:725 W ALDER ST STE 10
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4099
Practice Address - Country:US
Practice Address - Phone:406-529-5121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty