Provider Demographics
NPI:1154790814
Name:FARESE, STACY MARISSA
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MARISSA
Last Name:FARESE
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:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090-0186
Mailing Address - Country:US
Mailing Address - Phone:207-370-2483
Mailing Address - Fax:
Practice Address - Street 1:314 ALFRED ST
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-3102
Practice Address - Country:US
Practice Address - Phone:207-216-2637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC5472101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY10400OtherMEDICARE PTAN Y10400