Provider Demographics
NPI:1629561725
Name:LAWRENCE, STACEY JANE (MFT-INTERN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:JANE
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 S PAVILION CENTER DR UNIT 2079
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1849
Mailing Address - Country:US
Mailing Address - Phone:702-250-7636
Mailing Address - Fax:
Practice Address - Street 1:6655 W SAHARA AVE STE B200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-2832
Practice Address - Country:US
Practice Address - Phone:702-629-6982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI0840101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor