Provider Demographics
NPI:1922527514
Name:STACI M BOSTIC, LCSW
Entity Type:Organization
Organization Name:STACI M BOSTIC, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOSTIC
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:703-283-9083
Mailing Address - Street 1:43385 SPERRIN CT
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4548
Mailing Address - Country:US
Mailing Address - Phone:703-283-9083
Mailing Address - Fax:703-738-7258
Practice Address - Street 1:44075 PIPELINE PLZ STE 220
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5890
Practice Address - Country:US
Practice Address - Phone:703-283-9083
Practice Address - Fax:703-738-7258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-14
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040041161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1477645828OtherBLUE CROSS BLUE SHIELD OF VIRGINIA