Provider Demographics
NPI:1568476638
Name:NEAL, STACEY T (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:T
Last Name:NEAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:VIOLET MAPP
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7141 SECURITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1811
Mailing Address - Country:US
Mailing Address - Phone:443-663-6485
Mailing Address - Fax:443-663-6026
Practice Address - Street 1:7141 SECURITY BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-1811
Practice Address - Country:US
Practice Address - Phone:443-663-6015
Practice Address - Fax:443-663-6302
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00609292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD64758601OtherMD RENDERING #
MD550686OtherVALUE OPTIONS PROVIDER #
MD814276000OtherMIS #
MDT5140019OtherCAREFIRST REGIONAL PAR#
MD212150600Medicaid
MDT5140019OtherCAREFIRST REGIONAL PAR#