Provider Demographics
NPI:1679119754
Name:GREEN, STACY NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:NICOLE
Other - Last Name:SWEADNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:510 BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-9990
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-9990
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22391104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker