Provider Demographics
NPI:1164732749
Name:MARKS, STACEY LAQUITA (MSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LAQUITA
Last Name:MARKS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 PINEYWOODS PL
Mailing Address - Street 2:APT # 26
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-5094
Mailing Address - Country:US
Mailing Address - Phone:334-507-1005
Mailing Address - Fax:
Practice Address - Street 1:1321 MCMILLAN AVE
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1324
Practice Address - Country:US
Practice Address - Phone:251-867-3242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health