Provider Demographics
NPI:1902955503
Name:BENNETT, STACIE CAMP (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:CAMP
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 PAUL H. BEAM ROAD
Mailing Address - Street 2:
Mailing Address - City:CHERRYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28021
Mailing Address - Country:US
Mailing Address - Phone:704-301-8093
Mailing Address - Fax:704-301-8093
Practice Address - Street 1:809 N LAFAYETTE ST
Practice Address - Street 2:SUITE A
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3978
Practice Address - Country:US
Practice Address - Phone:704-301-8093
Practice Address - Fax:704-301-8093
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3813101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102552Medicaid