Provider Demographics
NPI:1952698706
Name:STACEY COUNSELING ASSOCIATES LLC
Entity Type:Organization
Organization Name:STACEY COUNSELING ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:STACEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:269-277-0025
Mailing Address - Street 1:50802 CHESTNUT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50740 PRINCESS WAY
Practice Address - Street 2:SUITE 700
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-4339
Practice Address - Country:US
Practice Address - Phone:269-277-0025
Practice Address - Fax:574-271-0479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN602763OtherICAADC