Provider Demographics
NPI:1194274761
Name:DIZZLEY-STREETER, STACIE MARIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:MARIE
Last Name:DIZZLEY-STREETER
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 1:194 CYPRESS FOREST DR
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-8441
Mailing Address - Country:US
Mailing Address - Phone:803-459-8022
Mailing Address - Fax:615-577-5654
Practice Address - Street 1:194 CYPRESS FOREST DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-8441
Practice Address - Country:US
Practice Address - Phone:803-459-8022
Practice Address - Fax:615-577-5654
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-17-27316103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst