Provider Demographics
NPI:1588778690
Name:WARD, STACEY S (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:S
Last Name:WARD
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 1:10720 CARMEL COMMONS BLVD
Mailing Address - Street 2:SUITE 320A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3785
Mailing Address - Country:US
Mailing Address - Phone:704-564-2931
Mailing Address - Fax:
Practice Address - Street 1:10720 CARMEL COMMONS BLVD
Practice Address - Street 2:SUITE 320A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3785
Practice Address - Country:US
Practice Address - Phone:704-564-2931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0053601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106413Medicaid