Provider Demographics
NPI:1619016672
Name:GOODPASTER, STACY NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:NICOLE
Last Name:GOODPASTER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5408 HURON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-2928
Mailing Address - Country:US
Mailing Address - Phone:734-329-3727
Mailing Address - Fax:
Practice Address - Street 1:26184 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2084
Practice Address - Country:US
Practice Address - Phone:133-389-7500
Practice Address - Fax:313-389-7510
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011041791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical