Provider Demographics
NPI:1154332013
Name:BLACK, STACEY DIANE (LCSW-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:DIANE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 N WALNUT ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-4738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 N WALNUT ST
Practice Address - Street 2:SUITE 300
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-4738
Practice Address - Country:US
Practice Address - Phone:301-766-7600
Practice Address - Fax:301-797-4976
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD099441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD121798OtherJOHN HOPKINS HEALTHCARE
MD614441-01OtherBCBS
MDPHCS 2233929OtherPHCS
MD520L85ZZMedicare ID - Type UnspecifiedMEDICARE