Provider Demographics
NPI:1689898033
Name:BILLINGTON, STACEY TARASKA (LICSW)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:TARASKA
Last Name:BILLINGTON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CUMMINGS CTR
Mailing Address - Street 2:SUITE 325A
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6115
Mailing Address - Country:US
Mailing Address - Phone:978-225-0595
Mailing Address - Fax:
Practice Address - Street 1:100 CUMMINGS CTR
Practice Address - Street 2:SUITE 325A
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6115
Practice Address - Country:US
Practice Address - Phone:978-225-0595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1155491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001519801Medicare PIN