Provider Demographics
NPI:1699148411
Name:MINER, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MINER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SCONTICUT NECK RD APT 5
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-1700
Mailing Address - Country:US
Mailing Address - Phone:413-522-4426
Mailing Address - Fax:
Practice Address - Street 1:279 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-2320
Practice Address - Country:US
Practice Address - Phone:508-679-0033
Practice Address - Fax:508-679-0037
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110028092B/CMedicaid