Provider Demographics
NPI:1841750197
Name:VAN BAALEN, STACIA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:ANN
Last Name:VAN BAALEN
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 1:13041 SW 95TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-5728
Mailing Address - Country:US
Mailing Address - Phone:305-282-1531
Mailing Address - Fax:
Practice Address - Street 1:19001 SW 106TH AVE # C-103
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-7669
Practice Address - Country:US
Practice Address - Phone:786-227-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW59931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1021ABMedicaid