Provider Demographics
NPI:1154893238
Name:STACY, DENISE MARIE (CADC)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:MARIE
Last Name:STACY
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 S WINCHESTER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60636-2614
Mailing Address - Country:US
Mailing Address - Phone:312-850-0050
Mailing Address - Fax:312-850-9095
Practice Address - Street 1:140 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1802
Practice Address - Country:US
Practice Address - Phone:312-850-0050
Practice Address - Fax:312-850-9095
Is Sole Proprietor?:No
Enumeration Date:2018-12-29
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL30989101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1568509719Medicaid