Provider Demographics
NPI:1124592050
Name:MONROE, STACEY LYNN
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:MONROE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:MONROE
Other - Last Name:KAISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:526 BEVERLY DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8191
Mailing Address - Country:US
Mailing Address - Phone:309-643-9926
Mailing Address - Fax:
Practice Address - Street 1:2855 TELEGRAPH AVE STE 515
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1151
Practice Address - Country:US
Practice Address - Phone:309-643-9926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0203971041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty