Provider Demographics
NPI:1376083766
Name:FARRIS, STACEY
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:FARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:JOBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:5 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:NY
Mailing Address - Zip Code:14727-1212
Mailing Address - Country:US
Mailing Address - Phone:716-307-2780
Mailing Address - Fax:
Practice Address - Street 1:5 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NY
Practice Address - Zip Code:14727-1212
Practice Address - Country:US
Practice Address - Phone:716-307-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004165-1101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor