Provider Demographics
NPI:1982178257
Name:STACIE DAVIS LLC
Entity Type:Organization
Organization Name:STACIE DAVIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:757-574-0303
Mailing Address - Street 1:501 CEDAR RD STE 2C
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-5527
Mailing Address - Country:US
Mailing Address - Phone:757-574-0303
Mailing Address - Fax:
Practice Address - Street 1:501 CEDAR RD STE 2C
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-5527
Practice Address - Country:US
Practice Address - Phone:757-574-0303
Practice Address - Fax:757-574-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-19
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1790860559Medicaid