Provider Demographics
NPI:1659393080
Name:BEARDEN, STACI NICOLE
Entity Type:Individual
Prefix:MS
First Name:STACI
Middle Name:NICOLE
Last Name:BEARDEN
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:PO BOX 748465
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8465
Mailing Address - Country:US
Mailing Address - Phone:855-284-7483
Mailing Address - Fax:617-807-0958
Practice Address - Street 1:4400 N MIDLAND DR STE 2910
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-3385
Practice Address - Country:US
Practice Address - Phone:855-284-7483
Practice Address - Fax:617-807-0958
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK#446101YP2500X
TX19619101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK446OtherALASKA LICENSE NUMBER
AK446OtherALASKA LICENSE NUMBER