Provider Demographics
NPI:1831392570
Name:STACHYRA, MARANDA ANNE (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARANDA
Middle Name:ANNE
Last Name:STACHYRA
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:MARANDA
Other - Middle Name:ANNE
Other - Last Name:HERBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:3600 SOUTH WATER TOWER PLACE
Mailing Address - Street 2:
Mailing Address - City:MT. VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-244-0212
Mailing Address - Fax:618-244-0535
Practice Address - Street 1:3600 SOUTH WATER TOWER PLACE
Practice Address - Street 2:
Practice Address - City:MT. VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-244-0212
Practice Address - Fax:618-244-0535
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0104801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.010480OtherPROFESSIONAL LICENSE