Provider Demographics
NPI:1194128264
Name:DAVIDSON, STACIE SMITH (LPCA)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:SMITH
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2284
Mailing Address - Country:US
Mailing Address - Phone:704-344-0491
Mailing Address - Fax:704-344-0493
Practice Address - Street 1:4601 PARK RD STE 400
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2284
Practice Address - Country:US
Practice Address - Phone:704-344-0491
Practice Address - Fax:704-344-0493
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10824101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health