Provider Demographics
NPI:1376009027
Name:RICCA, STACEY (LCSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:RICCA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:RAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 GAYLORD FARM RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2899
Mailing Address - Country:US
Mailing Address - Phone:203-284-2820
Mailing Address - Fax:
Practice Address - Street 1:50 GAYLORD FARM RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2899
Practice Address - Country:US
Practice Address - Phone:203-284-2820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT58.0100641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical