Provider Demographics
NPI:1013293182
Name:MEDLIN, STACIE M (LCSW)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:M
Last Name:MEDLIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 HIGHWAY 158
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870
Mailing Address - Country:US
Mailing Address - Phone:252-578-2273
Mailing Address - Fax:252-537-2278
Practice Address - Street 1:114 N RIVER ST
Practice Address - Street 2:
Practice Address - City:JARVISBURG
Practice Address - State:NC
Practice Address - Zip Code:27947-9522
Practice Address - Country:US
Practice Address - Phone:252-578-1986
Practice Address - Fax:252-537-2273
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0083291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical