MEDICARE: DEANNA L STACY MA, LCPC, NCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	180009845	IL

General Provider Information

NPI Number	:	1558784942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANNA L STACY MA, LCPC, NCC

Provider Business Mailing Address
First Line	:	15941 HARLEM AVE # 140
Second Line	:
City	:	TINLEY PARK
State	:	IL
Zip	:	60477-1609
Country	:	US
Telephone Number	:	779-435-4271
Fax Number	:

Provider Business Practice Location Address
First Line	:	15941 HARLEM AVE # 140
Second Line	:
City	:	TINLEY PARK
State	:	IL
Zip	:	60477-1609
Country	:	US
Telephone Number	:	779-435-4271
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2014
Last Update Date	:	07/27/2020

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