Provider Demographics
NPI:1043451818
Name:THAW, STACIE ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:ELLEN
Last Name:THAW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-2445
Mailing Address - Country:US
Mailing Address - Phone:516-316-1648
Mailing Address - Fax:
Practice Address - Street 1:115 PARK AVE
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-2445
Practice Address - Country:US
Practice Address - Phone:516-316-1648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0781761041C0700X
NY059664-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300113794Medicare PIN