Provider Demographics
NPI:1275259665
Name:ABBY, STACI (LCAT)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:ABBY
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2503 32ND ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-5011
Mailing Address - Country:US
Mailing Address - Phone:205-639-9304
Mailing Address - Fax:
Practice Address - Street 1:2503 32ND ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-5011
Practice Address - Country:US
Practice Address - Phone:205-639-9304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002410-01101200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist