Provider Demographics
NPI:1811547110
Name:GLICK, STACEY ALYNN (LMHC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ALYNN
Last Name:GLICK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 BOURNE HAY RD
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02563-2762
Mailing Address - Country:US
Mailing Address - Phone:508-577-9017
Mailing Address - Fax:
Practice Address - Street 1:704 MAIN ST
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-3200
Practice Address - Country:US
Practice Address - Phone:508-457-3160
Practice Address - Fax:508-457-1255
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4046101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health