Provider Demographics
NPI:1063505014
Name:PAUL, STACY L (MA, LPC, LICAC)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:L
Last Name:PAUL
Suffix:
Gender:F
Credentials:MA, LPC, LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 N ARROYO BLVD
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-2644
Mailing Address - Country:US
Mailing Address - Phone:520-287-4713
Mailing Address - Fax:520-287-9794
Practice Address - Street 1:590 S OCOTILLO AVE
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6405
Practice Address - Country:US
Practice Address - Phone:520-586-7080
Practice Address - Fax:520-586-3163
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC1626101YA0400X
AZLPC2397101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ644999OtherAHCCCS