Provider Demographics
NPI:1881848364
Name:BATES, STACEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6012 W WILLIAM CANNON DR
Mailing Address - Street 2:B-103
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1980
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6012 W WILLIAM CANNON DR
Practice Address - Street 2:B-103
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1980
Practice Address - Country:US
Practice Address - Phone:512-423-3146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33152103T00000X
TX32869103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool