Provider Demographics
NPI:1922487404
Name:WARNER, STACY J (LBA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:J
Last Name:WARNER
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:COHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33 TURNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-2108
Mailing Address - Country:US
Mailing Address - Phone:508-481-1015
Mailing Address - Fax:
Practice Address - Street 1:958 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-2901
Practice Address - Country:US
Practice Address - Phone:718-701-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001404103K00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist