Provider Demographics
NPI:1972379857
Name:ROMAN, STACY R (LMHC INTERN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:R
Last Name:ROMAN
Suffix:
Gender:F
Credentials:LMHC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 OAKLEAF WAY
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-9800
Mailing Address - Country:US
Mailing Address - Phone:702-300-0349
Mailing Address - Fax:
Practice Address - Street 1:8 OAKLEAF WAY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-9800
Practice Address - Country:US
Practice Address - Phone:702-300-0349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24189101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty