Provider Demographics
NPI:1649733189
Name:KING, STACEY (LPC IT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LPC IT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SUBSTANCE ABUSE
Mailing Address - Street 1:611A N 62ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-4171
Mailing Address - Country:US
Mailing Address - Phone:414-346-6423
Mailing Address - Fax:
Practice Address - Street 1:3900 W BROWN DEER RD STE 200
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209-1220
Practice Address - Country:US
Practice Address - Phone:414-540-2170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18842-130101YA0400X
WI7088-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)