Provider Demographics
NPI:1275380578
Name:FEDALE, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:FEDALE
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 1:8 FELDSPAR DR
Mailing Address - Street 2:
Mailing Address - City:CHADDS FORD
Mailing Address - State:PA
Mailing Address - Zip Code:19317-9226
Mailing Address - Country:US
Mailing Address - Phone:215-962-4721
Mailing Address - Fax:
Practice Address - Street 1:7 MOUNT LEBANON RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-1713
Practice Address - Country:US
Practice Address - Phone:302-464-0515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC-0011621101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health