Provider Demographics
NPI:1386167229
Name:ANDERSON, STACIE LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:LYNN
Other - Last Name:BEYRLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7015 A C SKINNER PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6932
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-363-2606
Practice Address - Street 1:2370 MARKET DR
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4326
Practice Address - Country:US
Practice Address - Phone:904-264-6201
Practice Address - Fax:904-264-6858
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW110601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical