Provider Demographics
NPI:1538369350
Name:WEBB, STACY L (RN, CSAC, ICS)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:WEBB
Suffix:
Gender:F
Credentials:RN, CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 UNDERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTELLO
Mailing Address - State:WI
Mailing Address - Zip Code:53949-9248
Mailing Address - Country:US
Mailing Address - Phone:608-297-3124
Mailing Address - Fax:608-297-8718
Practice Address - Street 1:480 UNDERWOOD AVE
Practice Address - Street 2:
Practice Address - City:MONTELLO
Practice Address - State:WI
Practice Address - Zip Code:53949-9248
Practice Address - Country:US
Practice Address - Phone:608-297-3181
Practice Address - Fax:608-297-2148
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15351-131101YA0400X
WI120614163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-178200Medicaid