Provider Demographics
NPI:1396484168
Name:STAGE, DESE'RAE LYNN (LCSW,MSW)
Entity type:Individual
Prefix:
First Name:DESE'RAE
Middle Name:LYNN
Last Name:STAGE
Suffix:
Gender:F
Credentials:LCSW,MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 MERCER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3625
Mailing Address - Country:US
Mailing Address - Phone:646-284-0618
Mailing Address - Fax:
Practice Address - Street 1:701 E CATHEDRAL RD STE 45-1395
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2128
Practice Address - Country:US
Practice Address - Phone:267-532-4494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW025097104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker