Provider Demographics
NPI:1376667329
Name:LISS, STACY L (MSW,LCSW)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:L
Last Name:LISS
Suffix:
Gender:F
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-6832
Mailing Address - Country:US
Mailing Address - Phone:732-923-0047
Mailing Address - Fax:
Practice Address - Street 1:520 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6832
Practice Address - Country:US
Practice Address - Phone:732-923-0047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC046150001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical