Provider Demographics
NPI:1972933927
Name:NOLAN-BROADWAY, STACIE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:NOLAN-BROADWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:MAE
Other - Last Name:NOLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1746 S M ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9740 S TACOMA WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98499-4456
Practice Address - Country:US
Practice Address - Phone:253-682-0320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst