Provider Demographics
NPI:1235235151
Name:EZEKWE, STACEY SUDIE (LSCSW)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:SUDIE
Last Name:EZEKWE
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SHAPE HEALTHCARE FACILITY
Mailing Address - Street 2:UNIT 21414 BOX 116
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09705
Mailing Address - Country:BE
Mailing Address - Phone:011326-544-5801
Mailing Address - Fax:011326-544-5809
Practice Address - Street 1:SHAPE HEALTHCARE FACILITY
Practice Address - Street 2:UNIT 21414 BOX 116
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09705
Practice Address - Country:BE
Practice Address - Phone:011326-544-5801
Practice Address - Fax:011326-544-5809
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical