Provider Demographics
NPI:1407162944
Name:MICHAELS, STACEY MAE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MAE
Last Name:MICHAELS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:MAE
Other - Last Name:GERARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:418 PINCKNEY COLONY RD
Mailing Address - Street 2:
Mailing Address - City:OKATE
Mailing Address - State:SC
Mailing Address - Zip Code:29909
Mailing Address - Country:US
Mailing Address - Phone:843-816-1789
Mailing Address - Fax:
Practice Address - Street 1:418 PINCKNEY COLONY RD
Practice Address - Street 2:
Practice Address - City:OKATE
Practice Address - State:SC
Practice Address - Zip Code:29909
Practice Address - Country:US
Practice Address - Phone:843-816-1789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-22
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCWP8916Medicaid