Provider Demographics
NPI:1033322169
Name:UEBERSAX, STACEY COLLEEN (PSYD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:COLLEEN
Last Name:UEBERSAX
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 CLIPPER PARK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-1405
Mailing Address - Country:US
Mailing Address - Phone:410-554-0099
Mailing Address - Fax:410-889-8971
Practice Address - Street 1:2002 CLIPPER PARK RD
Practice Address - Street 2:SUITE 110
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-1405
Practice Address - Country:US
Practice Address - Phone:410-554-0099
Practice Address - Fax:410-889-8971
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03962103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD03962OtherLICENSE NUMBER