Provider Demographics
NPI:1265101653
Name:ROBERTSON, STACEY DIANNE (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:DIANNE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:DIANNE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2345 S 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-3933
Mailing Address - Country:US
Mailing Address - Phone:708-752-6965
Mailing Address - Fax:
Practice Address - Street 1:2345 S 19TH AVE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3933
Practice Address - Country:US
Practice Address - Phone:708-752-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490102591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical