Provider Demographics
NPI:1063590313
Name:STACEY, LAURA M (MED, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:STACEY
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 W OCEAN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23503-1015
Mailing Address - Country:US
Mailing Address - Phone:757-362-8388
Mailing Address - Fax:757-210-3295
Practice Address - Street 1:1418 W OCEAN VIEW AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23503-1015
Practice Address - Country:US
Practice Address - Phone:757-362-8388
Practice Address - Fax:757-210-3295
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-06-2849103K00000X
VA0133000131103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0133000131OtherMEDICAL LICENSE
1-06-2849OtherBEHAVIOR ANALYST CERTIFICATION BOARD