Provider Demographics
NPI:1316164924
Name:MARCELLIN, STACIA JACKSON (LCSW)
Entity type:Individual
Prefix:MRS
First Name:STACIA
Middle Name:JACKSON
Last Name:MARCELLIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:LENNETTE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LGSW
Mailing Address - Street 1:5145 AVENING CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-8075
Mailing Address - Country:US
Mailing Address - Phone:704-405-7403
Mailing Address - Fax:
Practice Address - Street 1:5145 AVENING CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-8075
Practice Address - Country:US
Practice Address - Phone:704-405-7403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG119761041C0700X
NCP0039521041C0700X
NCC0061851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical