Provider Demographics
NPI:1154893550
Name:DEVAUX, STACEY (PSYD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:DEVAUX
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFF STA
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3172
Mailing Address - Country:US
Mailing Address - Phone:163-182-8030
Mailing Address - Fax:
Practice Address - Street 1:565 ROUTE 25A STE 201
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2600
Practice Address - Country:US
Practice Address - Phone:631-828-0307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-23
Last Update Date:2018-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016842103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016842OtherLICENSE