Provider Demographics
NPI:1215018593
Name:WEIRES, STACIE LARAE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LARAE
Last Name:WEIRES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-5810
Mailing Address - Country:US
Mailing Address - Phone:515-238-1947
Mailing Address - Fax:
Practice Address - Street 1:950 OFFICE PARK RD
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-2549
Practice Address - Country:US
Practice Address - Phone:515-279-2834
Practice Address - Fax:515-279-4168
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA057461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA492664000Medicaid
IAIB2455003Medicare UPIN