Provider Demographics
NPI:1285183335
Name:MCCLINTIC, STACY JO (MA, RD, CDN)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:JO
Last Name:MCCLINTIC
Suffix:
Gender:F
Credentials:MA, RD, CDN
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:JO
Other - Last Name:ROSENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:SUITE 2407
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-4304
Mailing Address - Fax:315-465-4301
Practice Address - Street 1:90 PRESIDENTIAL PLZ
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-4219
Practice Address - Fax:315-464-4218
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001947-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered