Provider Demographics
NPI:1619747607
Name:CARRASCO, STACY M
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:CARRASCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:766 MARY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-1843
Mailing Address - Country:US
Mailing Address - Phone:201-390-5198
Mailing Address - Fax:
Practice Address - Street 1:349 E 35TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-5001
Practice Address - Country:US
Practice Address - Phone:917-801-9150
Practice Address - Fax:929-567-2881
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency