Healthcare Provider Details

I. General information

NPI: 1972629434
Provider Name (Legal Business Name): STACEY BURRACK WATSON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W GOLF RD STE 16
ARLINGTON HEIGHTS IL
60005
US

IV. Provider business mailing address

415 W GOLF RD STE 16
ARLINGTON HEIGHTS IL
60005-3923
US

V. Phone/Fax

Practice location:
  • Phone: 847-577-0904
  • Fax: 847-577-1558
Mailing address:
  • Phone: 847-577-0904
  • Fax: 847-577-1558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180006108
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: