Provider Demographics
NPI:1619855103
Name:STACY, HERMAN
Entity type:Individual
Prefix:
First Name:HERMAN
Middle Name:
Last Name:STACY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 WOODWARD AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2136
Mailing Address - Country:US
Mailing Address - Phone:313-334-1336
Mailing Address - Fax:
Practice Address - Street 1:8801 WOODWARD AVE STE 203
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2136
Practice Address - Country:US
Practice Address - Phone:313-334-1336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-23
Last Update Date:2025-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker