Provider Demographics
NPI:1962801001
Name:AUSTIN-ROOT, STACY (MS, LMHC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:AUSTIN-ROOT
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-2409
Mailing Address - Country:US
Mailing Address - Phone:315-592-4453
Mailing Address - Fax:315-598-7158
Practice Address - Street 1:301 BEECH ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2409
Practice Address - Country:US
Practice Address - Phone:315-592-4453
Practice Address - Fax:315-598-7158
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002763101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health