Provider Demographics
NPI:1902233430
Name:COON-BALLARD, STACEY MARIE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MARIE
Last Name:COON-BALLARD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 N MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-1377
Mailing Address - Country:US
Mailing Address - Phone:269-273-2024
Mailing Address - Fax:
Practice Address - Street 1:1519 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-1377
Practice Address - Country:US
Practice Address - Phone:269-273-2024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010957921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical