Provider Demographics
NPI:1790468569
Name:BODEN, STACEY KEANE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:KEANE
Last Name:BODEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:ANN
Other - Last Name:KEANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1970 CALUMET PKWY
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-7219
Mailing Address - Country:US
Mailing Address - Phone:757-289-2947
Mailing Address - Fax:
Practice Address - Street 1:300 TWINING ST # 760
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36112-6027
Practice Address - Country:US
Practice Address - Phone:334-953-3368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5267C-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical