Provider Demographics
NPI:1710077342
Name:BLICKER, STACEY BLAKE
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:BLAKE
Last Name:BLICKER
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 1:179 CAMERON CT
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3519
Mailing Address - Country:US
Mailing Address - Phone:954-349-4573
Mailing Address - Fax:954-495-8807
Practice Address - Street 1:179 CAMERON CT
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3519
Practice Address - Country:US
Practice Address - Phone:954-349-4573
Practice Address - Fax:954-495-8807
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker