Active NPI
Stacey Dianne Robertson, LCSW
- Clinical Social Worker
- Broadview, IL
National Provider Identifier
1265101653
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 149010259
- Practice address
- 2345 S 19TH Ave
Broadview, IL 60155-3933 - Phone
- (708) 752-6965
- NPI assigned
- Sep 8, 2021
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 149010259 | IL | Primary |
Addresses
Primary practice location
2345 S 19TH Ave
Broadview, IL 60155-3933
Mailing address
2345 S 19TH Ave
Broadview, IL 60155-3933
Phone (708) 752-6965
Other names 1
- Stacey Dianne Williams
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 149010259 | IL | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1631059200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1631059200000",
"number": "1265101653",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2345 S 19TH AVE",
"city": "BROADVIEW",
"state": "IL",
"postal_code": "601553933",
"telephone_number": "708-752-6965"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2345 S 19TH AVE",
"city": "BROADVIEW",
"state": "IL",
"postal_code": "601553933",
"telephone_number": "708-752-6965"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROBERTSON",
"first_name": "STACEY",
"middle_name": "DIANNE",
"credential": "LCSW",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2021-09-08",
"last_updated": "2021-09-08",
"certification_date": "2021-09-08",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "IL",
"license": "149010259",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"first_name": "STACEY",
"last_name": "WILLIAMS",
"middle_name": "DIANNE",
"credential": "LCSW",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Broadview, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 8, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.