Provider Demographics
NPI:1225069305
Name:BACON, STEPHANIE RUSSELL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:RUSSELL
Last Name:BACON
Suffix:
Gender:F
Credentials: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 2601
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27836-0601
Mailing Address - Country:US
Mailing Address - Phone:252-830-3925
Mailing Address - Fax:252-355-0539
Practice Address - Street 1:223 COMMERCE ST STE D
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5032
Practice Address - Country:US
Practice Address - Phone:252-830-3925
Practice Address - Fax:252-355-0539
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0046271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002768Medicaid