Provider Demographics
NPI:1629188909
Name:SOUZA, STACIE LYN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:LYN
Last Name:SOUZA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 LITTLE JOHN LN
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-5593
Mailing Address - Country:US
Mailing Address - Phone:401-273-7100
Mailing Address - Fax:401-525-2527
Practice Address - Street 1:830 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4734
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW00735101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health