Provider Demographics
NPI:1104320480
Name:BLACK, STACY ANNE
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18092 MONTBORNE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-8154
Mailing Address - Country:US
Mailing Address - Phone:618-979-0626
Mailing Address - Fax:
Practice Address - Street 1:2301 OLD HWY 99
Practice Address - Street 2:
Practice Address - City:MT. VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-398-5444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG60835827106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist