Provider Demographics
NPI:1942554951
Name:KILBURN, STACY LOUISE (LCSW, LMSW-C)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:LOUISE
Last Name:KILBURN
Suffix:
Gender:F
Credentials:LCSW, LMSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:248-835-9870
Mailing Address - Fax:
Practice Address - Street 1:823 GATEWAY CENTER WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4541
Practice Address - Country:US
Practice Address - Phone:619-515-2400
Practice Address - Fax:619-269-0906
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010930591041C0700X
CA1064331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical