Provider Demographics
NPI:1093820490
Name:STACY, ROOSEVELT (LCSW-S, LMFT-S)
Entity Type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:STACY
Suffix:
Gender:M
Credentials:LCSW-S, LMFT-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 E STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-2579
Mailing Address - Country:US
Mailing Address - Phone:281-762-8383
Mailing Address - Fax:281-762-8355
Practice Address - Street 1:1002 E STADIUM DR
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-2579
Practice Address - Country:US
Practice Address - Phone:281-762-8383
Practice Address - Fax:281-762-8355
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4979106H00000X
TX505571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist