Provider Demographics
NPI:1245750694
Name:STACY, MICHAELA MARIE
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:MARIE
Last Name:STACY
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 1:49 DUCK HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-7609
Mailing Address - Country:US
Mailing Address - Phone:443-907-4570
Mailing Address - Fax:
Practice Address - Street 1:11240 WAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6078
Practice Address - Country:US
Practice Address - Phone:703-237-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty