Provider Demographics
NPI:1326158353
Name:FORD, STACEY LYNN (LPC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:FORD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 VALENCIA DR
Mailing Address - Street 2:SUITE 137
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6313
Mailing Address - Country:US
Mailing Address - Phone:910-353-1957
Mailing Address - Fax:910-353-2516
Practice Address - Street 1:200 VALENCIA DR
Practice Address - Street 2:SUITE 137
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6313
Practice Address - Country:US
Practice Address - Phone:910-353-1957
Practice Address - Fax:910-353-2516
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5302101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional