Provider Demographics
NPI:1396259461
Name:TODD, STACEY LYN (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYN
Last Name:TODD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 BARRENS VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2344
Mailing Address - Country:US
Mailing Address - Phone:540-819-5579
Mailing Address - Fax:540-989-1705
Practice Address - Street 1:2965 COLONNADE DR STE 100
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3541
Practice Address - Country:US
Practice Address - Phone:540-989-1703
Practice Address - Fax:540-989-1705
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040102081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical