Healthcare Provider Details

I. General information

NPI: 1265976385
Provider Name (Legal Business Name): STACY BROWN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 WINDISH DRIVE
GALESBURG IL
61401
US

IV. Provider business mailing address

2323 WINDISH DR
GALESBURG IL
61401-9780
US

V. Phone/Fax

Practice location:
  • Phone: 309-344-4265
  • Fax: 309-344-4281
Mailing address:
  • Phone: 309-344-4265
  • Fax: 309-344-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180010313
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: