Provider Demographics
NPI:1841409695
Name:STACEY-SALL, PATRICIA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:STACEY-SALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8432
Mailing Address - Country:US
Mailing Address - Phone:904-396-2273
Mailing Address - Fax:904-396-2507
Practice Address - Street 1:1357 PALM AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8432
Practice Address - Country:US
Practice Address - Phone:904-396-2273
Practice Address - Fax:904-396-2507
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 14511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ5265Medicare ID - Type Unspecified