Provider Demographics
NPI:1073886107
Name:DAVISON, STACEY L (LCSW, SAC-T)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:DAVISON
Suffix:
Gender:F
Credentials:LCSW, SAC-T
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:HEINDL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3173 SHERMAN PARC CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037-8954
Mailing Address - Country:US
Mailing Address - Phone:414-491-2140
Mailing Address - Fax:
Practice Address - Street 1:3173 SHERMAN PARC CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WI
Practice Address - Zip Code:53037-8954
Practice Address - Country:US
Practice Address - Phone:414-491-2140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WI7889-123104100000X
WI16529-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)