Provider Demographics
NPI:1417577412
Name:STACEY TITUS PLLC
Entity Type:Organization
Organization Name:STACEY TITUS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TITUS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW38145
Authorized Official - Phone:208-860-2656
Mailing Address - Street 1:11868 W GUNSMOKE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-4753
Mailing Address - Country:US
Mailing Address - Phone:208-860-2656
Mailing Address - Fax:
Practice Address - Street 1:5440 W FRANKLIN RD STE 201
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-6434
Practice Address - Country:US
Practice Address - Phone:208-860-2656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty