Provider Demographics
NPI:1083921266
Name:HORNER, STACY B (MA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:B
Last Name:HORNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 INDUSTRIAL PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360
Mailing Address - Country:US
Mailing Address - Phone:508-830-1630
Mailing Address - Fax:
Practice Address - Street 1:64 INDUSTRIAL PARK ROAD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360
Practice Address - Country:US
Practice Address - Phone:508-830-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA685661OtherTUFTS
MA110026265EMedicaid