Provider Demographics
NPI:1902299324
Name:PETERSON, STACIE (LPCA)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8104 CONSELLA WAY
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRING
Mailing Address - State:NC
Mailing Address - Zip Code:27592-8945
Mailing Address - Country:US
Mailing Address - Phone:850-826-0976
Mailing Address - Fax:
Practice Address - Street 1:8104 CONSELLA WAY
Practice Address - Street 2:
Practice Address - City:WILLOW SPRING
Practice Address - State:NC
Practice Address - Zip Code:27592-8945
Practice Address - Country:US
Practice Address - Phone:850-826-0976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPCA 11188101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional