Healthcare Provider Details

I. General information

NPI: 1154893238
Provider Name (Legal Business Name): DENISE MARIE STACY CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2018
Last Update Date: 12/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N ASHLAND AVE
CHICAGO IL
60607-1802
US

IV. Provider business mailing address

6334 S WINCHESTER AVE FL 2
CHICAGO IL
60636-2614
US

V. Phone/Fax

Practice location:
  • Phone: 312-850-0050
  • Fax: 312-850-9095
Mailing address:
  • Phone: 312-850-0050
  • Fax: 312-850-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number30989
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: