Provider Demographics
NPI:1760904395
Name:STACY, MICHELLE LEIGH (AAC)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:LEIGH
Last Name:STACY
Suffix:
Gender:F
Credentials:AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1291
Mailing Address - Street 2:1900 NE OLD BELFAIR HWY
Mailing Address - City:BELFAIR
Mailing Address - State:WA
Mailing Address - Zip Code:98528-1291
Mailing Address - Country:US
Mailing Address - Phone:253-225-8408
Mailing Address - Fax:
Practice Address - Street 1:908 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501
Practice Address - Country:US
Practice Address - Phone:360-754-2423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60773757104100000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60773757OtherAAC - TELECARE