Provider Demographics
NPI:1477832558
Name:WILSON, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32366
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VILLAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99632-0366
Mailing Address - Country:US
Mailing Address - Phone:907-591-6295
Mailing Address - Fax:
Practice Address - Street 1:100 AIRPORT RD #366
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VILLAGE
Practice Address - State:AK
Practice Address - Zip Code:99632
Practice Address - Country:US
Practice Address - Phone:907-591-6295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care