Provider Demographics
NPI:1497528509
Name:PICKLES, STACIE (LCC)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:PICKLES
Suffix:
Gender:F
Credentials:LCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11531 E RAMONA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-4141
Mailing Address - Country:US
Mailing Address - Phone:602-399-9997
Mailing Address - Fax:
Practice Address - Street 1:11531 E RAMONA AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-4141
Practice Address - Country:US
Practice Address - Phone:602-399-9997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach