Provider Demographics
NPI:1609547223
Name:WIGELSWORTH, STACI FLORIE (MED, NCC, P-LPC)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:FLORIE
Last Name:WIGELSWORTH
Suffix:
Gender:F
Credentials:MED, NCC, P-LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3218
Mailing Address - Country:US
Mailing Address - Phone:601-636-5703
Mailing Address - Fax:
Practice Address - Street 1:1414 CHERRY ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3218
Practice Address - Country:US
Practice Address - Phone:601-636-5703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0728101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor