Provider Demographics
NPI:1407017239
Name:MACK, STACEY MICHELLE (MSW)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:MICHELLE
Last Name:MACK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:MICHELLE
Other - Last Name:MACK-CAMERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:3150 PACKARD RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1994
Mailing Address - Country:US
Mailing Address - Phone:734-879-0162
Mailing Address - Fax:734-879-0167
Practice Address - Street 1:3150 PACKARD RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1994
Practice Address - Country:US
Practice Address - Phone:734-879-0162
Practice Address - Fax:734-879-0167
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010817711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical