Provider Demographics
NPI:1992178784
Name:EDWARDS, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-1411
Mailing Address - Country:US
Mailing Address - Phone:609-828-3348
Mailing Address - Fax:
Practice Address - Street 1:232 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:PA
Practice Address - Zip Code:19050-1411
Practice Address - Country:US
Practice Address - Phone:609-828-3348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-11-8617103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABH001514OtherPENNSYLVANIA DEPT OF STATE BUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIRS
1-11-8617OtherBEHAVIOR ANALYST CERTIFICATION BOARD