Provider Information for 1891202446
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STACEY CANTRELL LPC
Sex: Female
NPI: 1891202446
Last Updated: 2018-06-16
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1891202446 | ||||||||
| Enumeration Date | 2018-01-04 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 5230 6TH STREET FRONTAGE RD E SPRINGFIELD, IL 62703-5128 United States Phone: 217-585-1180 | Fax:217-585-4747 | ||||||||
| Primary Practice Address | 5230 6TH STREET FRONTAGE RD E SPRINGFIELD, IL 62703-5128 United States Phone: 217-585-1180 | Fax:217-585-4747 | ||||||||
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