Provider Demographics
NPI:1336538545
Name:SIMON, STACEY (LPCC-S)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 CHESTERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-2212
Mailing Address - Country:US
Mailing Address - Phone:419-704-7409
Mailing Address - Fax:
Practice Address - Street 1:204 W WAYNE ST STE 210-7
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-2125
Practice Address - Country:US
Practice Address - Phone:419-359-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1700029101YM0800X
OHE.1700029-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty