Provider Demographics
NPI:1295884559
Name:STAGMAN, TERRY LOU (PHD)
Entity type:Individual
Prefix:MS
First Name:TERRY
Middle Name:LOU
Last Name:STAGMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE STREET
Mailing Address - Street 2:SUITE LL38
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1015
Mailing Address - Country:US
Mailing Address - Phone:312-565-2838
Mailing Address - Fax:312-207-0162
Practice Address - Street 1:1100 LAKE STREET
Practice Address - Street 2:SUITE LL38
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1015
Practice Address - Country:US
Practice Address - Phone:312-565-2838
Practice Address - Fax:312-207-0162
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002979103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical