Provider Demographics
NPI:1861523680
Name:PROVIDENCE COUNSELING ASSOCIATES, LLC
Entity type:Organization
Organization Name:PROVIDENCE COUNSELING ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:SPACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-420-2596
Mailing Address - Street 1:445 W JACKSON AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-5258
Mailing Address - Country:US
Mailing Address - Phone:630-420-2596
Mailing Address - Fax:630-420-2796
Practice Address - Street 1:445 W JACKSON AVE STE 206
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-5258
Practice Address - Country:US
Practice Address - Phone:630-420-2596
Practice Address - Fax:630-420-2796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0032240364OtherBLUECROSSBLUESHIELD