Provider Demographics
NPI:1003900275
Name:WEISS, STACEY S (MS)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:S
Last Name:WEISS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E7475 STATE ROAD 12
Mailing Address - Street 2:
Mailing Address - City:ELK MOUND
Mailing Address - State:WI
Mailing Address - Zip Code:54739-9261
Mailing Address - Country:US
Mailing Address - Phone:715-235-1602
Mailing Address - Fax:
Practice Address - Street 1:808 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2735
Practice Address - Country:US
Practice Address - Phone:715-232-1116
Practice Address - Fax:715-232-5987
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI807-122104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker