Provider Demographics
NPI:1851487979
Name:FOSTER, STACEY BOGUE (LICSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:BOGUE
Last Name:FOSTER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 WAVERLY ROAD
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01845-3599
Mailing Address - Country:US
Mailing Address - Phone:978-794-1545
Mailing Address - Fax:978-794-2508
Practice Address - Street 1:266 WAVERLY ROAD
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01832
Practice Address - Country:US
Practice Address - Phone:978-794-1545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2110431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA211043OtherLICENSE