Provider Demographics
NPI:1104829589
Name:MASTEN, STACY E (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:E
Last Name:MASTEN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:AZ
Mailing Address - Zip Code:86329-0486
Mailing Address - Country:US
Mailing Address - Phone:928-777-0919
Mailing Address - Fax:928-777-8897
Practice Address - Street 1:804 AINSWORTH DR
Practice Address - Street 2:STE 105
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1624
Practice Address - Country:US
Practice Address - Phone:928-777-0919
Practice Address - Fax:928-777-8897
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW34691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ748337Medicaid
AZZ70714Medicare ID - Type Unspecified