Provider Demographics
NPI:1215395744
Name:KHALIFA, STACEY (LISW-CP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KHALIFA
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6439 GARNERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1638
Mailing Address - Country:US
Mailing Address - Phone:803-776-4000
Mailing Address - Fax:803-695-8078
Practice Address - Street 1:160 MEDICAL CIR FL 1
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:803-796-6811
Practice Address - Fax:803-796-6851
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical