Provider Demographics
NPI:1912867870
Name:STACY, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:STACY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GREG
Other - Middle Name:
Other - Last Name:STACY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED
Mailing Address - Street 1:15 STACYS WAY
Mailing Address - Street 2:
Mailing Address - City:DENMARK
Mailing Address - State:ME
Mailing Address - Zip Code:04022-5331
Mailing Address - Country:US
Mailing Address - Phone:207-310-0418
Mailing Address - Fax:
Practice Address - Street 1:15 STACYS WAY
Practice Address - Street 2:
Practice Address - City:DENMARK
Practice Address - State:ME
Practice Address - Zip Code:04022-5331
Practice Address - Country:US
Practice Address - Phone:207-310-0418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2122101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)