Provider Demographics
NPI:1275358269
Name:BATEMAN, STACY BROOKE (MA CAS, NCSP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:BROOKE
Last Name:BATEMAN
Suffix:
Gender:F
Credentials:MA CAS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7897 CHALICE RD
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-1403
Mailing Address - Country:US
Mailing Address - Phone:410-916-6361
Mailing Address - Fax:
Practice Address - Street 1:15 W GUDE DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-1153
Practice Address - Country:US
Practice Address - Phone:240-740-3381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool