Provider Demographics
NPI:1275024473
Name:SUTTON, STACEY (LBS)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SUTTON
Suffix:
Gender:F
Credentials:LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 CREEKSIDE LN UNIT 512
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-3275
Mailing Address - Country:US
Mailing Address - Phone:215-668-0234
Mailing Address - Fax:
Practice Address - Street 1:45 CREEKSIDE LN UNIT 512
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3275
Practice Address - Country:US
Practice Address - Phone:215-668-0234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
PABH002255103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst