Provider Demographics
NPI:1992018170
Name:BURDGE, STACIE ANN (LCPC)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:ANN
Last Name:BURDGE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5852
Mailing Address - Country:US
Mailing Address - Phone:301-791-3045
Mailing Address - Fax:240-313-3071
Practice Address - Street 1:1180 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5852
Practice Address - Country:US
Practice Address - Phone:301-791-3045
Practice Address - Fax:240-313-3071
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3567101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional