Provider Demographics
NPI:1124429071
Name:TATE, STACEY (MED, LPC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 PINE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5434
Mailing Address - Country:US
Mailing Address - Phone:405-923-3036
Mailing Address - Fax:
Practice Address - Street 1:307 E DANFORTH RD STE 118
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-4484
Practice Address - Country:US
Practice Address - Phone:405-285-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5452101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health