Provider Demographics
NPI:1306922190
Name:FITCH, STACIA (LCSW, LADC)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:FITCH
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 EGYPT RD
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:ME
Mailing Address - Zip Code:04071-6390
Mailing Address - Country:US
Mailing Address - Phone:207-329-8670
Mailing Address - Fax:
Practice Address - Street 1:465 CONGRESS ST STE 700
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3539
Practice Address - Country:US
Practice Address - Phone:207-329-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MPLC904101YA0400X
MELC55141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical