Provider Demographics
NPI:1407252174
Name:HARRIS, STACEY MARIE (LCSW #253840)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCSW #253840
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 MCMAHAN BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2240
Mailing Address - Country:US
Mailing Address - Phone:502-418-2825
Mailing Address - Fax:
Practice Address - Street 1:3109 MCMAHAN BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2240
Practice Address - Country:US
Practice Address - Phone:502-418-2825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-07
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2538401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical