Provider Demographics
NPI:1699158055
Name:STACY, CHRISTINA (LPC)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:STACY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 VIREO DR
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3135
Mailing Address - Country:US
Mailing Address - Phone:706-414-6362
Mailing Address - Fax:
Practice Address - Street 1:4325 WASHINGTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3966
Practice Address - Country:US
Practice Address - Phone:706-888-0299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPC007274101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional