=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568969640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY DENISE SEITZ LPC, NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2018
-----------------------------------------------------
Last Update Date | 04/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 E STATE AVE
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-2342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-860-4148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3581 N RHONE PL
-----------------------------------------------------
City | STAR
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83669-5449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-860-4148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------