Provider Demographics
NPI:1972081842
Name:LANDRIE, STACEY MICHELLE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
Last Name:LANDRIE
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 1:828 AIRPAX RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-6401
Mailing Address - Country:US
Mailing Address - Phone:410-901-1333
Mailing Address - Fax:
Practice Address - Street 1:828 AIRPAX RD STE 300
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-6401
Practice Address - Country:US
Practice Address - Phone:410-901-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1770906901Medicaid