Provider Demographics
NPI:1366922155
Name:CHAMBERLAIN, STACY R (LMAC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:R
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:LMAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6331 W 110TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1509
Mailing Address - Country:US
Mailing Address - Phone:913-696-1911
Mailing Address - Fax:913-696-1619
Practice Address - Street 1:6331 W 110TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1509
Practice Address - Country:US
Practice Address - Phone:913-696-1911
Practice Address - Fax:913-696-1619
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS204101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS204OtherBEHAVIORAL SCIENCES REGULATORY BOARD