Provider Demographics
NPI:1588190862
Name:STACY, WALLACE JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:
Last Name:STACY
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 RICHDALE DR APT A
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-2008
Mailing Address - Country:US
Mailing Address - Phone:914-309-6442
Mailing Address - Fax:
Practice Address - Street 1:21 RICHDALE DR APT A
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-2008
Practice Address - Country:US
Practice Address - Phone:914-309-6442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0079361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical