Provider Demographics
NPI:1295217628
Name:WILSON, STACEY JANETTE (LMFTA)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:JANETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 MICHIGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519
Mailing Address - Country:US
Mailing Address - Phone:832-867-6767
Mailing Address - Fax:
Practice Address - Street 1:235 MICHIGAN AVENUE
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519
Practice Address - Country:US
Practice Address - Phone:832-867-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-01
Last Update Date:2018-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12115A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist