Provider Demographics
NPI:1750505855
Name:CASANOVA, STACEY LYNN (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:CASANOVA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-2409
Mailing Address - Country:US
Mailing Address - Phone:517-392-1268
Mailing Address - Fax:
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:SUITE 800
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-780-3304
Practice Address - Fax:517-787-1765
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801079359104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801079359OtherSTATE SOCIAL WORK LICENSE