Healthcare Provider Details

I. General information

NPI: 1861523680
Provider Name (Legal Business Name): PROVIDENCE COUNSELING ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 03/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 W JACKSON AVE STE 206
NAPERVILLE IL
60540-5258
US

IV. Provider business mailing address

445 W JACKSON AVE STE 206
NAPERVILLE IL
60540-5258
US

V. Phone/Fax

Practice location:
  • Phone: 630-420-2596
  • Fax: 630-420-2796
Mailing address:
  • Phone: 630-420-2596
  • Fax: 630-420-2796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. STEPHANIE JOY SPACKEY
Title or Position: MANAGING MEMBER
Credential: PSY.D.
Phone: 630-420-2596