Provider Demographics
NPI:1760735765
Name:WALDEN, STACY LEANN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LEANN
Last Name:WALDEN
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 1:1 CHILDRENS WAY
Mailing Address - Street 2:SLOT 512-39
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-526-8700
Mailing Address - Fax:501-526-8740
Practice Address - Street 1:118 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-7328
Practice Address - Country:US
Practice Address - Phone:501-305-3305
Practice Address - Fax:501-279-0760
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2870-B104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker