Healthcare Provider Details

I. General information

NPI: 1124592050
Provider Name (Legal Business Name): STACEY LYNN MONROE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STACEY MONROE KAISER LCSW

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 TELEGRAPH AVE STE 515
BERKELEY CA
94705-1151
US

IV. Provider business mailing address

526 BEVERLY DR
SUMMERVILLE SC
29485-8191
US

V. Phone/Fax

Practice location:
  • Phone: 309-643-9926
  • Fax:
Mailing address:
  • Phone: 309-643-9926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.020397
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: