Provider Demographics
NPI:1861628380
Name:CLARK, STACY (M ED)
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2156 SEASTONE TRCE
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3777
Mailing Address - Country:US
Mailing Address - Phone:757-405-6015
Mailing Address - Fax:
Practice Address - Street 1:2156 SEASTONE TRCE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3777
Practice Address - Country:US
Practice Address - Phone:757-803-5261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor