Provider Demographics
NPI:1962427443
Name:DAVIS, STACEY J (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:DAVIS
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 1:113 GATESWAY DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655
Mailing Address - Country:US
Mailing Address - Phone:870-723-5324
Mailing Address - Fax:
Practice Address - Street 1:790 ROBERTS DR
Practice Address - Street 2:DELTA COUNSELING ASSOC
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655
Practice Address - Country:US
Practice Address - Phone:870-367-2461
Practice Address - Fax:870-367-1690
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1380C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
5U665OtherBLUE CROSS BLUE SHIELD
5U665OtherBLUE CROSS BLUE SHIELD