Provider Demographics
NPI:1689709800
Name:EZERSKY, STACEY R (LCSW C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:EZERSKY
Suffix:
Gender:F
Credentials:LCSW C
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:R
Other - Last Name:SELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW C
Mailing Address - Street 1:3635 OLD COURT RD STE 305
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-3907
Mailing Address - Country:US
Mailing Address - Phone:443-898-8308
Mailing Address - Fax:443-327-4753
Practice Address - Street 1:3635 OLD COURT RD STE 305
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-3907
Practice Address - Country:US
Practice Address - Phone:443-898-8308
Practice Address - Fax:443-327-4753
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD134001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD412244500Medicaid