Provider Demographics
NPI:1104307289
Name:JUSTICE, STACY (LICSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:JUSTICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:RENAISSANCE MEDICAL GROUP
Mailing Address - Street 2:11-15 SAUNDERSDALE ROAD
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RENAISSANCE MEDICAL GROUP
Practice Address - Street 2:11-15 SAUNDERSDALE ROAD
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550
Practice Address - Country:US
Practice Address - Phone:508-479-2563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
MA1200391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health