Provider Demographics
NPI:1043594401
Name:STUBBLEFIELD, CAROLYN JANE (MA, LPC-S)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JANE
Last Name:STUBBLEFIELD
Suffix:
Gender:F
Credentials:MA, LPC-S
Other - Prefix:
Other - First Name:JANIE
Other - Middle Name:
Other - Last Name:STUBBLEFIELD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LPC-S
Mailing Address - Street 1:1412 MAIN ST STE 613
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75202-4125
Mailing Address - Country:US
Mailing Address - Phone:214-542-5642
Mailing Address - Fax:
Practice Address - Street 1:4800 W LOVERS LN APT 118
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-3146
Practice Address - Country:US
Practice Address - Phone:214-542-5642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62980101YP2500X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1750824991Medicaid