Provider Demographics
NPI:1346482593
Name:HEAD, STACEY L (MA, LPC,LCDC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:HEAD
Suffix:
Gender:F
Credentials:MA, LPC,LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7819 CORONA CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-4787
Mailing Address - Country:US
Mailing Address - Phone:512-632-9244
Mailing Address - Fax:
Practice Address - Street 1:7819 CORONA CT
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76002-4787
Practice Address - Country:US
Practice Address - Phone:512-632-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63059101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200818701Medicaid