Provider Demographics
NPI:1063511681
Name:CRUESS, STACY ELLEN (PHD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ELLEN
Last Name:CRUESS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ELLEN
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:164 OTROBANDO AVE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2116
Mailing Address - Country:US
Mailing Address - Phone:860-425-8740
Mailing Address - Fax:
Practice Address - Street 1:164 OTROBANDO AVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2116
Practice Address - Country:US
Practice Address - Phone:860-425-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002704103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical