Provider Demographics
NPI:1871581231
Name:BLANK, STACEY ANNE (LPC)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ANNE
Last Name:BLANK
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 1:4670 GEORGETOWN DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-6231
Mailing Address - Country:US
Mailing Address - Phone:970-381-1239
Mailing Address - Fax:
Practice Address - Street 1:1401 S TAFT AVE STE 206
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537
Practice Address - Country:US
Practice Address - Phone:970-381-1239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3353101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health