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General NPI Number Information
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NPI Number | 1588630966
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Entity Type | Individual
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Provider Name | STACEY J CLOSSON LMHC
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Gender | Female
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Dates
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Enumeration Date | 02/27/2006
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Last Update Date | 06/03/2024
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Provider Practice Location Address
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Address Line | 2410 GRAPE RD STE 6
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City | MISHAWAKA
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State | IN
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Zip | 46545-3015
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Country | US
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Telephone | 574-283-1234
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Fax | 574-537-2652
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Provider Business Mailing Address
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Address Line | 10100 ELIDA RD
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City | DELPHOS
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State | OH
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Zip | 45833-9058
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Country | US
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Telephone | 419-695-8010
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Fax | 606-328-5153
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 39000588A
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License Number State | IN
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