Provider Demographics
NPI:1083866628
Name:HAILEY, STACEY TYWANNA
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:TYWANNA
Last Name:HAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7841 WALTERS RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28351-8947
Mailing Address - Country:US
Mailing Address - Phone:910-272-3220
Mailing Address - Fax:
Practice Address - Street 1:139 THREE HUNTS DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-6800
Practice Address - Country:US
Practice Address - Phone:910-272-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040076171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical