Provider Demographics
NPI:1730462433
Name:GATZ, STACY (LLP, CCSOTS)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GATZ
Suffix:
Gender:F
Credentials:LLP, CCSOTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:MI
Mailing Address - Zip Code:49224-1352
Mailing Address - Country:US
Mailing Address - Phone:269-449-1759
Mailing Address - Fax:
Practice Address - Street 1:501 UNION ST
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1368
Practice Address - Country:US
Practice Address - Phone:517-250-2552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011660103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral