Basic Information
| Provider Information | |||||||||
| NPI: | 1588039663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NAGORSKI | ||||||||
| FirstName: | STACIE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3160 REVERE RD | ||||||||
| Address2: | |||||||||
| City: | PLOVER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544673631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155707267 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4351 W COLLEGE AVE STE 410 | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004381772 | ||||||||
| FaxNumber: | 2623455562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2015 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6468-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 10049991 | 05 | WI | MEDICAID |