Healthcare Provider Details

I. General information

NPI: 1891402384
Provider Name (Legal Business Name): STACIE PETERSON, LCMHC, LPC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 S BRAGG BLVD
SPRING LAKE NC
28390-3929
US

IV. Provider business mailing address

614 ELWOOD DR
DUNCAN SC
29334-8995
US

V. Phone/Fax

Practice location:
  • Phone: 919-346-3733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11188
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerLCMHC LICENSE NUMBER

VIII. Authorized Official

Name: STACIE PETERSON
Title or Position: COUNSELOR
Credential:
Phone: 919-346-3733