Provider Demographics
NPI:1700364650
Name:SPRAGUE, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SPRAGUE
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 1:133 BRIMBAL AVE STE E
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 BRIMBAL AVE STE E
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1856
Practice Address - Country:US
Practice Address - Phone:978-921-2052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical