Provider Demographics
NPI:1639202815
Name:WELCH, STACEY TINKER (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:TINKER
Last Name:WELCH
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:E
Other - Last Name:TINKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NY
Mailing Address - Zip Code:14522-1424
Mailing Address - Country:US
Mailing Address - Phone:585-506-8928
Mailing Address - Fax:
Practice Address - Street 1:250 FAYETTE ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:NY
Practice Address - Zip Code:14522-1424
Practice Address - Country:US
Practice Address - Phone:585-506-8928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0729631041C0700X
NY07296311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07300072963Medicaid
NY07300072963Medicaid