Provider Demographics
NPI:1912035627
Name:STACY, JOHN JOSEPH (MLTDSW, CAC-1)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:STACY
Suffix:
Gender:M
Credentials:MLTDSW, CAC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:555 TOWNER ST
Mailing Address - Street 2:PO BOX 915
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5752
Mailing Address - Country:US
Mailing Address - Phone:734-544-3000
Mailing Address - Fax:734-544-6732
Practice Address - Street 1:2140 E ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2552
Practice Address - Country:US
Practice Address - Phone:734-222-9501
Practice Address - Fax:734-971-2487
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010877381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical