Provider Demographics
NPI:1437191335
Name:HERRICK, STACEY LEE (LCSW-R, ACSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:HERRICK
Suffix:
Gender:F
Credentials:LCSW-R, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ALLENS CREEK RD STE 240
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3306
Mailing Address - Country:US
Mailing Address - Phone:585-270-4055
Mailing Address - Fax:585-270-4220
Practice Address - Street 1:120 ALLENS CREEK RD STE 240
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3306
Practice Address - Country:US
Practice Address - Phone:585-270-4055
Practice Address - Fax:585-270-4220
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10058403R1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY262637150OtherUNITED BEHAVIORAL HEALTH
NY7295587OtherAETNA
NYP010058403OtherBLUE CROSS & BLUE SHEILD
NY146719FKOtherPREFERRED CARE