Provider Demographics
NPI:1457617920
Name:BRYSON-DES RAULT, STACI GLEE (LMHC)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:GLEE
Last Name:BRYSON-DES RAULT
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:STACI GLEE
Other - Middle Name:BRYSON
Other - Last Name:DES RAULT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:90 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-3051
Mailing Address - Country:US
Mailing Address - Phone:631-542-2501
Mailing Address - Fax:
Practice Address - Street 1:90 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-3051
Practice Address - Country:US
Practice Address - Phone:631-542-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005197101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)