Provider Demographics
NPI:1831693829
Name:SEALS, STACEY SHERRIE (LCPC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:SHERRIE
Last Name:SEALS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15010 S RAVINIA AVE STE 15
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-5353
Mailing Address - Country:US
Mailing Address - Phone:708-364-0580
Mailing Address - Fax:
Practice Address - Street 1:612 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4680
Practice Address - Country:US
Practice Address - Phone:330-331-9955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X
IL180012959101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL30527OtherCADC
IL178012565OtherLPC
IL30847OtherCODP I