Provider Demographics
NPI:1417025974
Name:STACY, MARDI (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARDI
Middle Name:
Last Name:STACY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-3949
Mailing Address - Country:US
Mailing Address - Phone:208-424-8130
Mailing Address - Fax:208-424-8137
Practice Address - Street 1:1718 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-3949
Practice Address - Country:US
Practice Address - Phone:208-424-8130
Practice Address - Fax:208-424-8137
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-429103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical