Provider Demographics
NPI:1134177678
Name:WILLSON, STACEY GRACE (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:GRACE
Last Name:WILLSON
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 1:200 N LAKEPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-6431
Mailing Address - Country:US
Mailing Address - Phone:337-412-8048
Mailing Address - Fax:
Practice Address - Street 1:200 N LAKEPOINTE DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-6431
Practice Address - Country:US
Practice Address - Phone:337-412-8048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX379761041C0700X
LA31561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX37976OtherSTATE LICENSE
TX37976OtherSTATE LICENSE