Provider Demographics
NPI:1972585495
Name:RODRIGUEZ, STACEY LYNN (LSCSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:MARTENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LBSW
Mailing Address - Street 1:555 N WOODLAWN ST
Mailing Address - Street 2:STE 3105
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3673
Mailing Address - Country:US
Mailing Address - Phone:316-651-1230
Mailing Address - Fax:316-685-0768
Practice Address - Street 1:555 N WOODLAWN ST
Practice Address - Street 2:STE 3105
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3673
Practice Address - Country:US
Practice Address - Phone:316-651-1230
Practice Address - Fax:316-685-0768
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS23271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS071010OtherBCBS PROVIDER NUMBER