Provider Demographics
NPI:1568116069
Name:STACY, KATRINA LYNN (LLMSW)
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:LYNN
Last Name:STACY
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 S DRAKE RD STE B
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3236
Mailing Address - Country:US
Mailing Address - Phone:269-779-7577
Mailing Address - Fax:269-888-2006
Practice Address - Street 1:487 S DRAKE RD STE B
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-3236
Practice Address - Country:US
Practice Address - Phone:269-779-7577
Practice Address - Fax:269-888-2006
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511106201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1407231996Medicaid